COUNSELING PROVIDER’S STATEMENT OF DETERMINATION
OPPPD/OUR CARE OUR CHOICE ACT 1 Counseling Provider Form
(eff. 1/1/19)
Instructions: Please provide this form to the Counseling Provider to complete and return to the
Attending Physician. The Counseling Provider must be a Hawai`i licensed psychiatrist,
psychologist or licensed clinical social worker who is qualified to determine that the patient is
capable (e.g. has the mental capacity) and does not appear to be suffering from undertreatment or
nontreatment of depression or other conditions which may interfere with the patient’s ability to
make an informed decision. (Optional: The counseling provider may conduct the evaluation via
telehealth.)
A. Patient Information
1. Full Name (Last, First, M.I.): ______________________________________
2. Date of Birth: __________________
B. Attending Physician’s Information
1. Full Name (Last, First, M.I.): _____________________________________
2. Address: _____________________________________________________
_______________________________________________________________
3. Phone Number: ________________________________________________
C. Counseling Provider’s Information
1. Full Name (Last, First, M.I.): _____________________________________
2. Address: _____________________________________________________
_______________________________________________________________
3. Phone Number: _______________________________________________
4. Email (if available): ____________________________________________
5. Profession (check one):
Psychiatrist Psychologist Licensed Clinical Social Worker
