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TOOLS & RESOURCES > Advance Care Directive Forms

What is an Advance Care Directive (ACD)?

An ACD is a way to make your healthcare wishes known if you are unable to speak for yourself or prefer someone else to speak for you. An ACD can serve one or both of these functions:

  • Power of Attorney for Healthcare (to appoint an agent)

  • Instructions for Healthcare (to indicate your wishes)

Why should I complete an ACD?

People of all ages may unexpectedly be in a position where they cannot speak for themselves, such as an accident or severe illness. In these situations, having an ACD assures that your doctor knows your wishes about the kind of care you want and/or who the person is that you want to make decisions on your behalf.

My form is complete.  Now what? 

We have provided submission details for hospitals in Napa below.

Advanced Care Directive Forms:

Below you will find several options for obtaining and completing the form:

Download and Send or Complete Online

The documents below provided by Common Good ACP will help you get the conversation started, choose  assistance, and complete the form.  

If you prefer to complete the form online, we developed an easy solution, guiding you through various considerations and decisions to be made.  At the end, you can print the form or simply choose your hospital and click submit!

Create a free account with Living Voice to get started, or review how it works for more information.

Download: 
Thinking Ahead (PDF*)

Thinking Ahead is an advance directive workbook and toolkit created by CCCC. This advance directive contains words, symbols and pictures that facilitate discussion and decision-making regarding values, goals and treatment preferences at the end of life. 

Although it was originally developed for use by persons with developmental disabilities, Thinking Ahead has proven to be a useful tool for all persons in need of articulating treatment preferences at the end of life.

 

Also available in SpanishChinese, and Korean

Written in plain English language, this form is intended to be read and understood easily, even by those who are unable to grasp complex legal language or have limited reading skills.

A slightly older version is available in: Chinese, Russian, Farsi, Korean, Vietnamese, Tagalog, and Armenian

ACD form in English
EasyRead_ACD_spanish_thumb.png
 
Submit the form to your hospital:

Once the document has been witnessed or notarized, it can be faxed or scanned and emailed to your hospital.  The document is not legally binding until witnessed or notarized.  

Queen of The Valley

Email: AD.QVMC@stjoe.org 

Fax: 707-257-4118

St. Helena Hospital   

Email: AHSHHIMadvancedDirectives@ah.org

Fax:  707-967-5625

*You may need to install the Adobe PDF Reader.