(Attach additional pages if more space is needed)
Section I -Identifying Information:
A. This plan is for:
____________________________________________________________________________________
Name (in full): ______________________________________________________________________ (Referred to throughout this guardianship plan as 'the person')
Address: ___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Telephone number: Residence __________________________________________________________ Business ___________________________________________________________
Date of Birth: _______________________________________________________________________
B. (1) As the proposed guardian of the person (or attorney for personal care) for ______________________________________________________________________,
I have consulted with the following persons in preparation of this guardianship plan:
the person identified in A. family members of the person
friends of the person care providers to the person
the person's guardian of property (attorney under a continuing power of attorney)
others (please specify relationship): _____________________________________________
Section II -Areas where personal care decision making authority is sought:
A. I am seeking personal care decision making authority in the following areas: (mark applicable boxes)
Health Care (Including decisions to which the Health Care Consent Act, 1996 applies)
Nutrition Shelter/ Accommodation
Clothing Hygiene
Safety
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B. Powers Requiring Specific Court Authorization (this section is only to be completed by applicants for court-appointed guardianship of the person):
1. I am asking the court for an order authorizing me to apprehend the person [Section 59 (3)].
Yes No
2. I am asking the court for an order authorizing me to change existing arrangements in respect of custody of or access to a child, or to give consent on the person's behalf to the adoption of a child
[Section 59( 4)].
Yes No
3. a) I am asking the court for an order permitting me to exercise other powers or perform other duties in addition to those set out in the Substitute Decisions Act, 1992 [Section 59( 2)( g)].
Yes No
b) If the answer to 3a is yes, please identify the other powers and duties: _________________________________________________________________________________
_________________________________________________________________________________ _________________________________________________________________________________
C. Notice Regarding Extraordinary Matters: The law limits or restricts a guardian's authority to make decisions in the following areas relating to
personal care:
Sterilization The law prohibits a substitute decision maker from consenting to non-therapeutic sterilization of a
person who is mentally incapable of such a decision. Any proposal to consent on behalf of the person to his or her sterlization as medically necessary for the protection of the person's health must
be consistent with the law and should appear in the Guardianship Plan or be the subject of an amendment to the Guardianship Plan prior to consent being given.
Regenerative Tissue Donation The law restricts the authority of a substitute decision maker regarding decisions to permit
regenerative tissue donations by a person who is mentally incapable of such a decision. Any proposal to authorize the removal of regenerative tissue for implantation in another person's body
must be consistent with the law and should appear in the Guardianship Plan or be the subject of an amendment to the Guardianship Plan prior to permission being given.
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Section III -The plan for personal decision making:
(Please complete only those sections where decision making authority is sought, and please attach any additional relevant documentation.)
HEALTH CARE (INCLUDING TREATMENT), NUTRITION AND HYGIENE
Background:
(a) Describe the current status of the health, nutrition and hygiene of the person, including all known health conditions for which treatment is being received or is proposed:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(b) Describe any wishes or instructions made by the person while capable that are known by you and that relate to his/ her preferences about health care, treatment, nutrition and hygiene and attach a copy of any
written wishes or instructions (e. g., a written advance directive, power of attorney for personal care, living will, etc.):
_________________________________________________________________________________________ _________________________________________________________________________________________
_________________________________________________________________________________________
Plan:
(c) Describe the long-term goals (2-6 years) for decisions under this heading: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(d) Describe the steps you propose to take (within the next 12 months) to achieve the goals under this heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
SHELTERING/ LIVING ARRANGEMENTS AND SAFETY
Background:
(a) Describe the current status of the person's living arrangements, including any factors relating to safety:
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__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(b) Describe any known wishes or instructions made by the person while capable that relate to his or her preferences about living arrangements and safety issues and attach a copy of any written wishes or
instructions:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Plan:
(c) Describe the long-term goals (2-6 years) for decisions under this heading: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(d) Describe the steps you propose to take (within the next 12 months) to achieve the goals under this heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
LEGAL PROCEEDINGS
Background:
(a) Describe the current status of any existing or anticipated legal proceedings relating to this person, (including divorce, custody, access, adoption, restraining orders, criminal matters, landlord and tenant
matters): __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(b) Describe any known wishes or instructions made by the person while capable that relate to his or her preferences about existing or anticipated legal proceedings and attach a copy of any written wishes or
instructions: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
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(c) If legal proceedings are in progress, describe arrangements for legal representation of the person, if known:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(d) Where there is a guardian of property or attorney under a continuing power of attorney, is he or she aware of the existing or anticipated legal proceedings described in (a)? If so, please describe his or her
involvement: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(e) Are you are aware of any existing court orders or judgments against the person? If yes, describe or attach copies:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(f) Is the person on probation or are there pending criminal proceedings in which the person is involved? If so, please provide details:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Plan:
(g) Describe the long-term goals (2-6 years) for decisions under this heading: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(h) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
EMPLOYMENT, EDUCATION AND TRAINING
Background:
(a) Is the person employed, or involved in any educational or training programs? If so, please describe current status:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
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(b) Describe any known wishes or instructions made by the person while capable that relate to his or her preferences about participation in employment, education or training programs:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Plan:
(c) Describe the long-term goals (2-6 years) for decisions under the heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(d) Describe the steps you propose to take (within the next 12 months) to achieve the goals under this heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
RECREATIONAL, SOCIAL AND CULTURAL ACTIVITIES
Background:
(a) Describe the activities that the person is involved in (or significant activities that the person was involved in), including hobbies, clubs, affiliations, volunteering:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(b) Describe any known wishes or instructions made by the person while capable that relate to his or preferences about participation in recreational, social and cultural activities:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Plan:
(c) Describe the long-term goals (2-6 years) for decisions under this heading: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
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(d) Describe the steps you propose to take (within the next 12 months) to achieve the goals under this heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
SOCIAL AND SUPPORT SERVICES
Background:
(a) Describe social and support services received by the person within the past year, including any services currently received:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(b) Describe any known wishes or instructions made by the person while capable that relate to his or her preferences about receipt of social and support services:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Plan:
(c) Describe the long-term goals (2-6 years) for decisions under this heading: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(d) Describe the steps you propose to take (within the next 12 months) to achieve the goals under this heading:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) Briefly describe your reasons for these plans: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
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Section IV -Additional Information:
(a) I have consulted with the person for whom guardianship is sought in making this plan: (check one)
Yes No
If no, please provide reasons: __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
(b) I have consulted with the following other people in preparing this plan: (please provide full names, addresses, telephone numbers and relationship to the person, of the people you consulted with)
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(c) If consultation did not occur with any of the persons identified in Section I-B (1) above, provide reasons why:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(d) To the best of my knowledge, the person for whom guardianship is sought would not object to any aspect of this guardianship plan: (check one)
Yes, would object No, would not object
If yes, please explain:
__________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
(e) I am aware of my duty as a guardian of the person to foster the person's independ-ence, to encourage the person's participation in decisions I make on his or her behalf, and to consult with supportive family
and friends and caregivers. My plans to do so are as follows: (briefly describe) __________________________________________________________________________________________
__________________________________________________________________________________________ __________________________________________________________________________________________
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SUBSECTIONS 66 (15) AND 66 (16) OF THE SUBSTITUTE DECISIONS ACT, 1992 PROVIDE:
ss. 65( 15): A GUARDIAN SHALL ACT IN ACCORDANCE WITH THE GUARDIANSHIP PLAN.
ss. 66( 16): IF THERE IS A GUARDIANSHIP PLAN, IT MAY BE AMENDED FROM TIME TO TIME WITH THE PUBLIC GUARDIAN AND TRUSTEE'S APPROVAL.
SECTION 67 OF THE SUBSTITUTE DECISIONS ACT, 1992 PROVIDES:
s. 67: SECTION 66, EXCEPT SUBSECTION 66( 15) AND (16), APPLIES WITH NECESSARY MODIFICATIONS TO AN ATTORNEY WHO ACTS UNDER A
POWER OF ATTORNEY FOR PERSONAL CARE.
SUBSECTIONS 89 (5) AND 89 (6) OF THE SUBSTITUTE DECISIONS ACT, 1992 PROVIDE:
ss. 89( 5): NO PERSON SHALL, IN A STATEMENT MADE IN A PRESCRIBED FORM, ASSERT SOMETHING THAT HE OR SHE KNOWS TO BE UNTRUE OR
PROFESS AN OPINION THAT HE OR SHE DOES NOT HOLD.
ss. 89( 6): A PERSON WHO CONTRAVENES SUBSECTION (5) IS GUILTY OF AN OFFENCE AND IS LIABLE, ON CONVICTION, TO A FINE NOT
EXCEEDING $10,000.002
_________________________________________________________________________________________ Date Signature of proposed Guardian( s)/
Attorney( s) for Personal Care Name( s): _________________________________________________________________________________
Address( es): ______________________________________________________________________________ _________________________________________________________________________________________
Telephone Number( s): Residence: _________________________ Business: ____________________________
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