Source: https://www.global-regulation.com/law/canada/503556/adult-guardianship-and-trusteeship-%2528ministerial%2529-regulation.html
Timestamp: 2018-04-24 07:05:19
Document Index: 72278878

Matched Legal Cases: ['art 1', 'art 2', 'art 3', 'art 1', 'art 2', 'art 1', 'art 3', 'art 3', 'art 1', 'art 1', 'art 1']

Adult Guardianship and Trusteeship (Ministerial) Regulation (Canada)
Adult Guardianship and Trusteeship (Ministerial) Regulation
Link to law: http://www.qp.alberta.ca/1266.cfm?page=2009_224.cfm≤g_type=Regs&isbncln=9780779764785&display=html
AR 224/2009 ADULT GUARDIANSHIP AND TRUSTEESHIP (MINISTERIAL) REGULATION (Consolidated up to 77/2012)
ALBERTA REGULATION AR 224/2009
2 Persons eligible to be supporter
3 Supported decision‑making authorizations
4 Powers and responsibilities of supporters
5 Validity of supported decision‑making authorizations
6 Standards of conduct for capacity assessors
1 In this Regulation, “Act” means the Adult Guardianship and Trusteeship Act.
Persons eligible to be supporter
2 An adult may appoint as a supporter a person who
(a) consents to act as a supporter,
(b) is not an assisted adult or represented adult, and
(c) does not have (i) a personal directive that is in effect, or
(ii) an enduring power of attorney that is in effect because of the incapacity of the person.
Supported decision‑making authorizations
3(1) A supported decision‑making authorization must be
(a) signed by the adult making the authorization or a person acting on behalf of the adult under subsection (4) in the presence of the witness referred to in clause (b), and
(b) witnessed by an adult who
(i) is not named as a supporter in the authorization, and
(ii) did not sign the authorization on behalf of the adult.
(2) A supported decision‑making authorization must contain the consent of each person appointed as a supporter in the authorization.
(3) An amendment to or termination of a supported decision‑making authorization must be
(b) signed and dated by the supported adult or by a person acting on the supported adult’s behalf under subsection (4), and
(c) witnessed by an adult who
(i) is not appointed as a supporter in the authorization, and
(4) If an adult who is making, amending or terminating a supported decision‑making authorization is not physically able to sign the authorization, amendment or termination, an adult who is not named as a supporter in the supported decision‑making authorization may, at the direction of the adult, sign the authorization, amendment or termination on behalf of the adult.
(5) A person who signs a supported decision‑making authorization or an amendment to or termination of a supported decision‑making authorization on behalf of an adult shall, in the presence of the adult and the witness, sign his or her own name and indicate that he or she has signed on behalf of the adult.
Powers and responsibilities of supporters
4(1) A supporter shall exercise the supporter’s powers and responsibilities
(a) in the supported adult’s best interests,
(b) diligently, and
(c) in good faith.
(2) A supporter shall keep a written record of all decisions that the supported adult makes or communicates by or with the assistance of the supporter.
(3) If a supporter accesses, collects or obtains personal information about the supported adult from a public body, custodian or organization, the supporter shall keep a written record of
(a) the reason for accessing, collecting or obtaining the personal information,
(b) the name of the public body, custodian or organization that provides access to the personal information or from whom the personal information is collected or obtained,
(c) a brief description of the personal information that is accessed, collected or obtained, and
(d) the date on which the personal information is accessed, collected or obtained.
(4) If a supporter uses or discloses personal information referred to in subsection (3), the supporter shall keep a written record of
(a) the reason for using or disclosing the personal information,
(b) a brief description of the personal information that is used or disclosed,
(c) the name of any person to whom the personal information is disclosed, and
(d) the date on which the personal information is used or disclosed.
(5) A supporter shall retain a written record referred to in subsections (2) to (4) for at least 2 years after the day on which the supporter ceases to have authority under the supported decision‑making authorization.
Validity of supported decision‑making authorizations
5(1) If a supported decision‑making authorization purports to give powers to a supporter respecting the financial matters of the supported adult, the supported decision‑making authorization is not valid to the extent that it purports to give a supporter those powers.
(2) A supported decision‑making authorization is not valid unless
(a) it is in Form 1 as set out in the Schedule, and
(b) it includes a termination of any previous supported decision‑making authorization.
Standards of conduct for capacity assessors
6 A person who is designated as a capacity assessor shall conduct himself or herself in accordance with the following standards:
(a) when conducting a capacity assessment, a capacity assessor shall
(i) comply with the guidelines for conducting capacity assessments established by the Minister;
(ii) exercise care and diligence;
(iii) act in good faith;
(iv) have regard to the fact that
(A) the adult who is undergoing the capacity assessment is presumed to have the capacity to make decisions until the contrary is determined, and
(B) the adult who is undergoing the capacity assessment is entitled to communicate by any means that enables the adult to be understood, and the means by which the adult communicates is not relevant to a determination of whether the adult has the capacity to make decisions;
(b) a capacity assessor shall maintain his or her professional competency to conduct capacity assessments.
7(1) The form for a supported decision‑making authorization for the purposes of section 4(3) of the Act is set out in Form 1 in the Schedule.
(2) A termination of a supported decision‑making authorization for the purposes of section 7(2) of the Act must be in the form set out in
(a) item 1 of Form 1 in the Schedule, or
(b) Form 2 in the Schedule.
(3) The form for a capacity assessment report in respect of an application for a co‑decision‑making order is set out in Form 3 in the Schedule.
(4) The form for a capacity assessment report in respect of an application for a guardianship order or trusteeship order is set out in Form 4 in the Schedule.
(5) The form for a complaint for the purposes of section 75 of the Act is set out in Form 5 in the Schedule.
(6) An assessment of an adult’s capacity to make a decision respecting the adult’s health care or the adult’s temporary admission to or discharge from a residential facility, for the purposes of section 87 of the Act, must be in the form set out in Part 1 of Form 6 in the Schedule.
(7) A declaration of a specific decision maker for the purposes of section 90 of the Act must be in the form set out in Part 2 of Form 6 in the Schedule.
(8) A written record that a health care provider is required to keep for the purposes of section 91 of the Act must be in the form set out in Part 3 of Form 6 in the Schedule.
(9) Repealed AR 47/2010 s2. (10) The form for a capacity assessment report for the purposes of section 96 of the Act is set out in Form 10 in the Schedule.
AR 224/2009 s7;47/2010
8 For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on September 30, 2019.
9 This Regulation comes into force on the coming into force of the Adult Guardianship and Trusteeship Act.
Supported Decision‑making Authorization
I, _____________________________________, am a resident of Alberta and make this supported decision‑making authorization.
1 Termination of previous supported decision‑making authorization
I terminate all previous supported decision‑making authorizations made by me. (initials of supported person and witness)
2 Appointment of supporter(s)
I appoint the following person(s) as my supporter(s):
(a) (name of supporter) ; (initials of supported person and witness)
(b) (name of supporter) ; (initials of supported person and witness)
(c) (name of supporter) . (initials of supported person and witness)
(Under section 4(1) of the Act, a maximum of 3 supporters may be appointed.)
3 Decisions respecting personal matters for which supporter has authority
My supporter(s) has (have) authority in respect of decisions to be made by me relating to the following personal matters:
(personal matters) ; (initials of supported person and witness)
(Note: See the definition of “personal matter” in section 1(bb) of the Act.)
4 Authority of supporter(s)
I give my supporter(s) the authority to (check the relevant boxes and initial at the end):
□ (a) access, collect or obtain or assist me in accessing, collecting or obtaining from any person any information that is relevant to the decision(s) related to the personal matters specified in item 3 and to assist me in understanding the information; ________(initials of supported person and witness)
□ (b) assist me in making the decision(s) related to the personal matters specified in item 3; (initials of supported person and witness)
□ (c) communicate or assist me in communicating the decision(s) related to the personal matters specified in item 3 to other persons. (initials of supported person and witness)
(Note: If (a) is checked, the supporter(s) should refer to section 9 of the Act and section 4(3) to (5) of this Regulation for details about the supporter’s authority and responsibilities.)
5 Effective dates of supported decision‑making authorization
This supported decision‑making authorization has effect from _______________________ to ___________________.
6 Consent of supporters
I consent to act as a supporter:
(signature of supporter) (printed name of supporter)
Signed by me in the presence of (name of witness) at (location) in the Province of Alberta this (day) of (month) , (year) .
(signature of supported adult in the presence of the witness)
(signature of witness in the presence of the supported adult)
(printed name and address of witness)
(Note: Witness should also initial provisions initialled by supported adult.)
Termination of Supported Decision‑making Authorization
I, _____________________________________, terminate the supported decision‑making authorization that I made on (date) .
Capacity Assessment Report (Co‑decision-making)
(This form of capacity assessment report is to be used in respect of an application for a co-decision-making order.)
“capacity” means, in respect of the making of a decision about a matter, the ability to understand the information that is relevant to the decision and to appreciate the reasonably foreseeable consequences of
(a) a decision, and
(b) a failure to make a decision;
“significantly impaired”, in respect of an adult’s capacity to make decisions, means that the adult’s cognitive and adaptive abilities
(a) are substantially limited as the result of an impairment, including, without limitation, a developmental disability, an organic, degenerative or neurological disease or disorder, an acquired brain injury or a chronic mental illness, and
(b) are not so substantially limited that the adult would not have the capacity to make decisions with appropriate guidance and support.
1. I, (name of the capacity assessor) , am a registered member of the (name of the capacity assessor’s professional college) .
If the capacity assessor is not a physician or registered psychologist, the capacity assessor must complete the following:
□ I am currently designated as a capacity assessor under the Act. My designation is dated _ (day/month/year) .
1.1. This capacity assessment report is about (name of the adult) of (address of the adult) , whose date of birth is (date of birth of the adult) .
2. The reason(s) or circumstances leading up to the request for this capacity assessment are:
3. I have obtained confirmation that a medical evaluation of the adult was conducted by (name of physician) on (day/month/year) (must be within the 3‑month period immediately preceding the capacity assessment) and that the results of the medical evaluation did not indicate that the adult was suffering from a reversible temporary medical condition that appeared likely to have a significant impact on his or her capacity to make a decision about a personal matter.
3.1. The adult
□ (a) has been diagnosed by a physician as having the following medical condition(s) that is (are) relevant to this capacity assessment:
(diagnosis) (name of physician) (day/month/year) ,
□ (b) has not been diagnosed by a physician as having a medical condition that is relevant to this capacity assessment.
4. Prior to conducting an assessment of the capacity of (name of the adult) (“the adult”) I met with the adult and I explained to him or her
(a) the purpose and nature of the capacity assessment,
(b) that he or she has the right to refuse
(i) to undergo the capacity assessment, or
(ii) to continue with the capacity assessment at any point during the capacity assessment,
(c) that he or she has the right to have
(i) a person present to assist him or her in feeling comfortable and relaxed when undergoing the capacity assessment, and
(ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate his or her capacity during the capacity assessment,
(d) that if, in my opinion, a person who is present to assist the adult during the capacity assessment is interfering with the capacity assessment, the person may be asked to leave, and
(e) the significance and effect of a finding that his or her capacity to make decisions respecting a personal matter is significantly impaired.
5. The adult
□ (a) has not refused to undergo or to continue with the capacity assessment, and
□ (i) in my opinion, the adult
(A) understands the purpose of the capacity assessment and that he or she has a right to refuse to undergo or continue with the capacity assessment,
(B) appears to be capable of consenting to the capacity assessment, and
(C) has consented to the capacity assessment,
□ (ii) in my opinion
(A) the adult appears not to be capable of consenting to the capacity assessment, and
(B) it is in the best interests of the adult to conduct the capacity assessment,
□ (b) has refused to undergo or to continue with the capacity assessment.
If (b) is checked,
□ (i) a capacity assessment was not conducted, or
□ (ii) the capacity assessment was discontinued.
6. I have determined that
□ (a) it is not necessary for the adult to have and the adult has not requested to have
(i) a person present to assist the adult in feeling comfortable and relaxed when undergoing the capacity assessment, or
□ (b) it is necessary for the adult to have or the adult has requested to have
(ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate his or her capacity during the capacity assessment.
If (b) is checked, set out what is considered necessary or what the adult has requested, as the case may be, as well as the steps taken to have a person present or to provide the adult with the assistance of a person or device.
7. Based on the information that was provided to me, I have determined that an assessment of the capacity of the adult to make decisions is warranted with respect to the following personal matter(s):
□ (a) the adult’s health care;
□ (b) where, with whom and under what conditions the adult is to live, either permanently or temporarily;
□ (c) with whom the adult may associate;
□ (d) the adult’s participation in social activities;
□ (e) the adult’s participation in any educational, vocational or other training;
□ (f) the adult’s employment;
□ (g) the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult.
8. I asked the adult if there have been any significant changes recently in his or her beliefs and values related to making decisions about the personal matter(s) identified in item 7 and the adult informed me that
□ (a) there have been significant changes recently in his or her beliefs and values related to making decisions about the matter(s), or
□ (b) there have not been significant changes recently in his or her beliefs and values related to making decisions about the matter(s).
9. I assessed the capacity of the adult to make decisions about each personal matter identified in item 7 and my opinion respecting his or her capacity to make decisions about the personal matter(s) is indicated in column 1 or 2 below, as the case may be:
Adult has capacity Capacity of adult is significantly impaired Personal Matter □ □ the adult’s health care □ □ where, with whom and under what conditions the adult is to live, either permanently or temporarily □ □ with whom the adult may associate □ □ the adult’s participation in social activities □ □ the adult’s participation in any educational, vocational or other training □ □ the adult’s employment □ □ the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult □ □ other (specify)
(Note: Cross out any matter in column 3 that is not identified in item 7.)
(set out the reasons) In forming my opinion about the adult’s capacity to make decisions about the personal matter(s),
(a) I considered the adult’s ability to understand the information that is relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision and a failure to make a decision about the personal matter(s), and
(b) I took into account
(i) whether the adult has the ability to retain information that is relevant to decisions about the personal matter(s), and
(ii) the following additional factors, if any: (specify) .
10. In my opinion the adult has the capacity to consent to
(a) the appointment of any individual who is proposed to be appointed as a co‑decision‑maker, and
(b) a co‑decision‑making order.
11. If in item 9 I have stated that in my opinion the capacity of the adult to make decisions about one or more personal matters is significantly impaired, I have considered whether the adult is likely to regain some or all of his or her capacity to make decisions about the matter(s) and I believe that the adult
□ (a) is likely to regain some or all of his or her capacity to make decisions about the matter(s), or
(set out the reasons)
□ (b) is not likely to regain some or all of his or her capacity to make decisions about the matter(s).
If (a) is checked, complete the following:
If the Court appoints a co‑decision‑maker for the adult, I recommend that another capacity assessment of the adult be conducted no later than (day) of (month) , (year) .
12. I have attached more detailed information respecting the capacity assessment. (Optional) □ Yes □ No
Dated at (location) in the Province of Alberta this (day) of (month) , (year) .
(signature of capacity assessor)
Capacity Assessment Report (Guardianship or Trusteeship or both)
(This form of capacity assessment report is to be used in respect of an application for a guardianship order or trusteeship order or both.)
(b) a failure to make a decision.
□ I am currently designated as a capacity assessor under the Act. My designation is dated (day/month/year) .
3. I have obtained confirmation that a medical evaluation of the adult was conducted by (name of physician) on (day/month/ year) (must be within the 3‑month period immediately preceding the capacity assessment) and that the results of the medical evaluation did not indicate that the adult was suffering from a reversible temporary medical condition that appeared likely to have a significant impact on his or her capacity to make a decision about a personal matter or financial matters.
4. Prior to conducting an assessment of the capacity of (name of the adult) (“the adult”) I met with the adult and, unless the level of consciousness of the adult was such that the adult was non‑responsive, I explained to him or her
(e) the significance and effect of a finding that he or she does not have the capacity to make decisions respecting a personal matter or a financial matter.
(NOTE: Provide any comments you may have. If the level of consciousness of the adult was such that the adult was non‑responsive you must indicate that here.)
(A) understands the purpose of the capacity assessment and that he or she has a right to refuse to undergo or to continue with the capacity assessment,
(B) it is in the best interests of the adult to conduct the capacity assessment;
7. Based on the information that was provided to me, I have determined that an assessment of the capacity of the adult to make decisions is warranted
□ (a) with respect to the following personal matter(s):
□ (i) the adult’s health care;
□ (ii) where, with whom and under what conditions the adult is to live, either permanently or temporarily;
□ (iii) with whom the adult may associate;
□ (iv) the adult’s participation in social activities;
□ (v) the adult’s participation in any educational, vocational or other training;
□ (vi) the adult’s employment;
□(vii) the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult;
□ (b) with respect to financial matters.
8. Unless the level of consciousness of the adult was such that the adult was non‑responsive, I asked the adult if there have been any significant changes recently in his or her beliefs and values related to making decisions about the matter(s) identified in item 7 and the adult informed me that
(NOTE: Provide any comments you may have. If the level of consciousness of the adult was such that the adult was non‑responsive, you must indicate that here.)
9. The level of consciousness of the adult at the time of the capacity assessment was
□ (a) alert,
□ (b) fluctuating, or
□ (c) non‑responsive.
10. I assessed the capacity of the adult to make decisions about the matter(s) identified in item 7 and my opinion respecting his or her capacity to make decisions about the matter(s) is indicated in column 1 or 2, as the case may be:
Adult has capacity Adult does not have capacity Matter □ □
(a) personal matter(s)
(i) the adult’s health care
(ii) where, with whom and under what conditions the adult is to live, either permanently or temporarily
(iii) with whom the adult may associate
(iv) the adult’s participation in social activities
(v) the adult’s participation in any educational, vocational or other training
(vi) the adult’s employment
(vii) the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult
(viii) other (specify)
(set out the reasons) In forming my opinion about the adult’s capacity to make decisions about the matter(s),
(a) I considered the adult’s ability to understand the information that is relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision and a failure to make a decision about the matter(s), and
(i) whether the adult has the ability to retain information that is relevant to decisions about the matter(s), and
11. In my opinion, serving the adult with notice of an application for a guardianship or trusteeship order
□ (a) is likely to cause serious emotional or physical harm to the adult, or
□ (b) is not likely to cause serious emotional or physical harm to the adult.
12. If in item 10 I have stated that in my opinion the adult does not have the capacity to make decisions about one or more matter(s), I have considered whether the adult is likely to regain some or all of his or her capacity to make decisions about the matter(s) and I believe that the adult
□ (a) is likely to regain some or all of his or her capacity to make decisions about the matter(s);
If the court appoints a guardian or trustee for the adult, I recommend that another capacity assessment of the adult be conducted by no later than (day) of (month) , (year) .
13. I have attached more detailed information respecting the capacity assessment. (Optional) □ Yes □ No
Complaint Respecting a Co‑decision‑maker, Guardian or Trustee
(a) What is your name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)?
(b) What is your relationship to the assisted adult or represented adult?
2 Information about the assisted adult or represented adult (if known)
What is the assisted adult’s or represented adult’s name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)?
3 Information about the co-decision-maker, guardian or trustee who is the subject of your complaint (if known)
What is the co‑decision-maker’s or guardian’s or trustee’s name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)?
4 Information about the co‑decision-making, guardianship or trusteeship order (if known)
Provide any other relevant information you have about the co‑decision-making, guardianship or trusteeship order. (For example, the matters with respect to which the co‑decision maker, guardian or trustee has authority.)
5 Nature of your complaint
(a) What are your reasons for believing the co‑decision‑maker, guardian or trustee is failing to comply with the co‑decision‑making, guardianship or trusteeship order or the duties of a co‑decision‑maker, guardian or trustee? Include the date or time period when your concerns arose.
(b) What are your reasons for believing that the failure is
(i) likely to cause harm to the physical or mental health of the assisted adult or represented adult?
(ii) likely to cause financial loss to the represented adult?
(c) Have you taken any steps to resolve the matter? Set out the details in the space below.
6 People who can provide further information
Provide the full name, title (if any), address and preferred telephone contact number and alternate telephone number (if any), of any person who may be able to provide further information about this complaint or about the assisted adult’s or represented adult’s circumstances and set out the person’s relationship to the assisted adult or represented adult.
(NOTE: If the subject‑matter of your complaint could be an offence under the Criminal Code (Canada), abuse against a client under the Protection for Persons in Care Act or an offence under another statute or regulation of Alberta, the complaints officer may refer the complaint to a police service or appropriate government ministry in accordance with s79(1) of the Adult Guardianship and Trusteeship Act.)
Signature of person making complaint
The personal information you have provided is being collected under section 78 of the Adult Guardianship and Trusteeship Act and may be used for the purposes of conducting an investigation or resolving a complaint under sections 75 to 79 of the Adult Guardianship and Trusteeship Act, making an application under section 26, 46 or 74 of the Adult Guardianship and Trusteeship Act or as authorized or required under the Freedom of Information and Protection of Privacy Act or another enactment. If you have any questions about this collection, you may contact the complaints officer at the Office of the Public Guardian.
Specific Decision Making
Part 1 - Assessment of Capacity
1. I, (name of physician, nurse practitioner or dentist) , met with (name of the adult) (“the adult”) on (day/month/year) to assess the adult’s capacity to make a decision to consent or refuse to consent to
□ (a) the following proposed health care for the adult:
(describe the proposed health care)
□ (b) the adult’s proposed
□ (i) temporary admission to, or
□ (ii) discharge from
the following residential facility or type of residential facility, as the case may be:
(set out the name or type of proposed residential facility, including a transitional facility) .
2. I certify that, in conducting the assessment, I complied with the requirements of sections 18, 19 and 20 of the Adult Guardianship and Trusteeship Regulation (“AGTR”), including but not limited to the requirements to inform the adult of his or her right to refuse to be assessed and to provide the adult with the information that a reasonable person would require to make the decision referred to in item 1 above.
□ (check if applicable) I am unable to certify that the adult comprehended the information.
3. It is my assessment that the adult
□ (a) has the capacity to make the decision described in item 1 above, because the adult
(i) understands the information that is relevant to the decision, and
(ii) appreciates the reasonably foreseeable consequences of the decision and of failing to make the decision,
□ (b) does not have the capacity to make the decision described in item 1 above, because the adult
(i) does not understand the information that is relevant to the decision, and
(ii) does not appreciate the reasonably foreseeable consequences of the decision and of failing to make the decision.
4. (Complete this item only if item 3(b) is selected) I have informed the adult that I assessed the adult as not having the capacity to make a decision to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 above, and I have advised the adult of his or her rights under sections 96 and 97 of the Adult Guardianship and Trusteeship Act (“AGTA”) in compliance with section 21 of the AGTR.
(name of physician, nurse practitioner or dentist conducting the assessment)
(signature of physician, nurse practitioner or dentist conducting the assessment)
Part 2 - Declaration of Specific Decision Maker
1. I, (name of specific decision maker) have been selected by (name of physician, nurse practitioner or dentist who selected the specific decision maker) to make a decision for (name of the adult) to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 of Part 1 of this form.
2. I understand that I am not authorized to make the decision referred to in item 1 above until I have made this declaration.
3. I declare that I (a) am 18 years of age or older, (b) am available and willing to make the decision, (c) am able to make the decision, (d) have been in contact with the adult in the previous 12 months, (e) have knowledge of the adult’s wishes respecting the decision to be made or of the beliefs and values of the adult, (f) do not have a dispute with the adult that might affect my ability to comply with the duties of a specific decision maker, (g) will carry out the duties and responsibilities of a specific decision maker, and (h) will comply with the requirements of Part 3, Division 1 of the AGTA in making a decision for the adult.
4. I have been given a pamphlet outlining my responsibilities and the restrictions on my authority under the AGTA and its Regulations.
5. I understand that I am required to make reasonable efforts to notify the nearest relative of the adult of the decision made and to notify the Public Guardian of the decision made if I am not able to notify the nearest relative.
(name of specific decision maker)
(mailing or street address of specific decision maker)
(signature of specific decision maker)
Part 3 - Record of Health Care Provider
1. I selected (name of specific decision maker) to make a decision for (name of the adult) to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 of Part 1 of this form.
2. The specific decision maker made the following specific decision for the adult on (day/month/year) :
□ (a) that the adult receive the health care described in item 1 of Part 1 of this form, specifically:
□ (b) that the adult be
□ (i) temporarily admitted to, or
□ (ii) discharged from
the residential facility or type of residential facility set out in item 1 of Part 1 of this form, specifically:
(name of physician, nurse practitioner or dentist who conducted the assessment)
(signature of physician, nurse practitioner or dentist who conducted the assessment)
Forms 7 to 9 Repealed AR 47/2010 s3.
Capacity Assessment Report (Section 96 of the Act, Health Care or Temporary Admission to or Discharge from a Residential Facility)
(This form of capacity assessment report is to be used in respect of a capacity assessment under section 96 of the Act.)
3. Repealed AR 77/2012 s2.
(e) the significance and effect of a finding that he or she does not have the capacity to make a decision respecting a personal matter or a financial matter.
(C) has consented to the capacity assessment, or
If (b) is checked, set out what is considered necessary or what the adult has requested, as the case may be, as well as the steps taken to have a person present or provide the adult with the assistance of a person or device.
7. I have determined that an assessment of the capacity of the adult to make decisions is warranted with respect to the adult’s
□ (a) health care,
□ (b) temporary admission to a residential facility, or
□ (c) discharge from a residential facility.
8. I have asked the adult if there have been any significant changes recently in his or her beliefs and values related to making decisions about the personal matters identified in item 7 and the adult has informed me that
□ (a) there have been significant changes recently in his or her beliefs and values related to making decisions about those personal matters, or
□ (b) there have not been significant changes recently in his or her beliefs and values related to making decisions about those personal matters.
□ (a) alert, or
□ (b) fluctuating.
10. I assessed the capacity of the adult to make the decision about
□ (a) his or her health care, and in my opinion he or she
□ (i) has the capacity to make the decision, because he or she has, or
□ (ii) does not have the capacity to make the decision, because he or she does not have
the ability to understand the information that is relevant to the decision about his or her health care and to appreciate the reasonably foreseeable consequences of the decision or a failure to make the decision about his or her health care for the following reasons:
(set out the reasons for the opinion)
□ (b) his or her temporary admission to a residential facility, and in my opinion he or she
the ability to understand the information that is relevant to the decision about his or her temporary admission to a residential facility and to appreciate the reasonably foreseeable consequences of the decision or a failure to make the decision about his or her temporary admission to a residential facility for the following reasons:
□ (c) his or her discharge from the residential facility, and in my opinion he or she
the ability to understand the information that is relevant to the decision about his or her discharge from the residential facility and to appreciate the reasonably foreseeable consequences of the decision or a failure to make the decision about his or her discharge from the residential facility for the following reasons:
11. In forming my opinion about the matter referred to in item 10, I took into account the following:
□ (a) whether the adult has the ability to retain information that is relevant to decisions;
□ (b) the following:
(set out additional matters, if any)
12. In my opinion, the adult
□ (a) has the capacity to make decisions about his or her
□ (i) health care,
□ (ii) temporary admission to a residential facility, or
□ (iii) discharge from a residential facility,
□ (b) does not have the capacity to make decisions about his or her
□ (iii) discharge from a residential facility.
13. If in item 12 I have stated that in my opinion the adult does not have the capacity to make the decision about the health care or temporary admission to or discharge from a residential facility, I have considered whether the adult is likely to regain some or all of his or her capacity to make the decision, and I believe that the adult
□ (a) is likely to regain some or all of his or her capacity to make decisions (the decision) about his or her
□ (iii) discharge from a residential facility;
□ (b) is not likely to regain some or all of his or her capacity to make decisions (the decision) about his or her
If a specific decision maker is appointed for the adult, I recommend that another capacity assessment of the adult be conducted no later than (day) of (month) , (year) .
14. I have attached more detailed information respecting the capacity assessment. (Optional) □ Yes □ No
___(signature of capacity assessor)__
AR 224/2009 Sched.;47/2010;77/2012