Form 11: Consent of Proposed Assisted Adult - Alberta Human Services - Government of Alberta

Form 11: Consent of Proposed Assisted Adult

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This document tells the Court that the Adult is consenting to the appointment of a person(s) as their co-decision-maker.

Please read all the sections carefully.

Court file number: Leave blank. if you do not yet have a Court file number.

Judicial Centre: Leave blank. The application will be made in the appropriate judicial centre having regard to where the assisted adult (hereafter referred to as the adult) resides.

Adult’s Full Name: fill in full legal name of the adult. Do not use nicknames or abbreviations. Use the same name all the way through the documents.

Applicant’s name: fill in full legal name of the person making the application; do not use nicknames or abbreviations. Use the same name throughout the documents.

1. Enter the adult’s name. The adult will be signing this form at the bottom.

2. Enter the complete name(s) of the co-decision-maker(s).

3. Please refer to the capacity assessment report when completing this list as the assessor will have identified areas in which he/she believes that the adult needs a co-decision-maker. The Court can only grant authority in areas where it considers a co-decision-maker necessary. Your choices should also match your application Form 1 or Form 6 (if you are completing a review).

If you are selecting the last box (“any other personal matters”) you will need to write in the decision that you feel needs to be made and make sure that it does not fit in an area already identified, e.g. attending church services would not need to go into this section because it would be covered under social activities.

4. and 5. Please read all sections carefully.

The Adult is to date and sign the document in the presence of a witness and have the witness sign the document and print their name. The witness can be anyone over the age of 18 other than the/any co-decision-maker(s) for the adult.

Modified: 2015-04-21
PID: 16389

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