Every Hawaii patient seeking medical aid in dying must be evaluated by a counseling provider under the Our Care, Our Choice Act. The counseling provider records the evaluation date and determines that the patient has the mental capacity to make an informed decision and does not appear to suffer from undertreated or untreated depression or another condition interfering with that decision.
A Hawaii-licensed psychiatrist, psychologist, LCSW, LMFT, or APRN with a psychiatric or clinical nurse specialization completes and signs the form, checking the attestation for their license type.
Download the current version from the source each time; forms change without notice.
Counseling Provider's Statement of Determination Form
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A Hawaii-licensed psychiatrist, psychologist, licensed clinical social worker, licensed marriage and family therapist, or APRN with a psychiatric or clinical nurse specialization who is qualified to determine that the patient has the mental capacity to make an informed health care decision.
Yes. The form states the counseling provider may conduct the evaluation via telehealth. The provider records the date of evaluation, signs the statement of determination and returns the form to the attending provider for the filing with the Department of Health.