The Psychologist Affidavit is used to assist individuals with selecting or obtaining an appropriate substitute decision-maker with DDA services who have been assessed to lack the capacity to make or effectively communicate medical decisions for themselves due to psychological issues.

Cross-References: Substitute-Decision Making for Emergency Care and Urgent Care Medical Needs Policy, Individual Support Plan Policy.

I have known ________ since _______. I have provided services to him/her since ______. In that regard, I have seen _________ on numerous
occasions, with the most recent psychological assessment completed on ________. I have also reviewed _________’s records and discussed him/her with other interdisciplinary team members. Based on my observations, my assessment, my review of the record and my discussion with other staff, it is my opinion that his/her cognitive functioning falls within the _________ range of mental retardation and adaptive functioning falls within the _________ range of mental retardation.

Six attachments (total)

1. Substitute Decision-Making for Non-Emergency Needs Procedure
2. Guardianship Routing and Approval Form
3. Medical Affidavit
4. Psychologist Affidavit
5. Service Coordination Affidavit
6. Substitute Consent for Health Care Decisions Form