CERTIFICATE OF CAPACITY

I, _______________________________, being a licensed ________________________

   ^{name                                                                                                                   physician or psychologist}

state that I know _________________________, and, as of the date of this statement,

believe him/her to have capacity to execute a health care advance directive in that s/he  understands the following:

his/her diagnosed condition

significant benefits, risks and alternatives to various treatment options 

the consequences of not accepting recommended treatment. 

I further believe that _____________________ can make and communicate a health care decision and understands the consequences of naming someone else to make health care decisions under a power of attorney.

Dated:            _______________________              _________________________________

                                                                        Name