Application for Assessment of Patient's Decision-Making Capacity

Medical Report

Office Use:

Purpose

A person who you have assessed and/or treated in a professional capacity (your patient) is the subject of an application before the State Administrative Tribunal (the Tribunal).

The Tribunal is required to determine your patient’s capability to make financial and personal decisions.

Your patient is presumed to be capable of making their own decisions unless the Tribunal determines that they are unable to do so.

The purpose of this form is to enable you to provide your views about your patient’s capability to make decisions in advance of the hearing. This information is essential as it allows the Tribunal to determine the application and to make decisions in your patient’s best interests.

Confidentiality

The information you provide about your patient is part of the information relied upon by the Tribunal to determine the application. It may be necessary for the Tribunal to disclose the information you provide to your patient and other interested parties to the proceedings.

Parties may be authorised to inspect documents held on file by the Tribunal, however they are not entitled to receive copies of documents. Parties are obliged to refrain from disclosing the contents of such documents to anyone else.

Parties who attend the hearing will be informed that you have provided this information at the request of the Tribunal.

Medical Professional Details

Full name:

Qualifications:

Agency or practice:

Address:

Telephone number:

Fax number:

Email address:

Patient Information

Full name:

Gender:

Date of birth:

Date you last saw your patient:

Number of times you have seen your patient in the past 12 months:

Length of time you have known your patient:

Is your patient usually accompanied by someone else when you see them? Yes No

If yes, please provide details:

If the accompanying person actively participates in the appointment, please indicate whether they:

Provide support to your patient;

Assist in communication between you and your patient (interpretation or explanation);

Provide information to you on behalf of your patient; and/or

Act as a substitute decision maker, giving informed consent to proposed treatment.

Please provide details of any other health professional/s that may have assessed or treated your patient within the past 12 months:

Cognitive Capacity Information

Cognitive Capacity Assessments

Have any assessments of cognitive capacity been performed?

Yes No Unsure

If yes, please attach a copy of the assessments.

The Tribunal is entitled to compel the production of documents relevant to determining an application. You are obliged to provide a copy of any document on which your opinion relies.

I have attached copies of all relevant documents in my possession.

Alternatively, if you do not have a copy please provide details of:

• the type of assessment conducted;

• when the assessment was carried out and by whom;

• the results of the assessment; and

• the implications or conclusions arising from these results.

Please provide details:

Mental Disability

In your opinion, does your patient have a mental disability?

This may include an intellectual disability, an acquired brain injury, a psychiatric condition or dementia.

Yes No Unclear diagnosis Not assessed

Please provide details of the diagnosis including when this disability or condition was first recognised:

Please indicate whether this disability or condition is:

Static Progressive Improving Fluctuating

If your patient has a mental disability do they currently have the cognitive capacity to make reasonable decisions in relation to:

a) Simple financial matters (such as managing a budget, payment of accounts, purchasing essential items):

Yes, capable No, incapable Unsure

Please provide details:

b) Complex financial decisions (such as management of property or large sums of money, purchase or sale of significant assets, pursuing entitlements including income and superannuation, advocating for own interests with financial institutions):

Yes, capable No, incapable Unsure

Please provide details:

c) Legal matters (such as ability to commence, defend or settle proceedings, whether of a personal or financial nature):

Yes, capable No, incapable Unsure

Please provide details:

Personal Decision Making

Does your patient currently have the capability to make reasonable decisions in relation to:

d) Medical treatment and procedures:

Yes, capable No, incapable Unsure

Please provide details:

e) Accommodation (such as identifying and securing housing that is appropriate to their care and support needs):

Yes, capable No, incapable Unsure

Please provide details:

f) Services (such as identifying and securing appropriate support services):

Yes, capable No, incapable Unsure

Please provide details:

Enduring Power of Attorney

An Enduring Power of Attorney is a legal document a person can prepare which gives someone else the authority to make financial and property decisions on their behalf.

Does your patient currently have the cognitive capacity to execute an Enduring Power of Attorney?

Yes, capable No, incapable Unsure

To your knowledge, has your patient previously executed an Enduring Power of Attorney?

Yes No Unsure

If Yes, please indicate whether you were involved in this process as a:

Witness: Yes No

Assessor of capacity: Yes No

Enduring Power of Guardianship

An Enduring Power of Guardianship is a legal document a person can prepare which gives someone else the power to make personal and health care decisions on their behalf.

Does your patient currently have the cognitive capacity to execute an Enduring Power of Guardianship?

Yes, capable No, incapable Unsure

To your knowledge, has your patient previously executed an Enduring Power of Guardianship?

Yes No Unsure

If Yes, please indicate whether you were involved in this process as a:

Witness: Yes No

Assessor of capacity: Yes No

Advance Health Directive

An Advance Health Directive is a legal document a person can prepare to enable them to make decisions now about the treatment they would want, or not want to receive.

Does your patient currently have the cognitive capacity to execute an Advance Health Directive?

Yes, capable No, incapable Unsure

To your knowledge, has your patient previously executed an Advance Health Directive?

Yes No Unsure

If Yes, please indicate whether you were involved in this process as a:

Witness: Yes No

Assessor of capacity: Yes No

Capacity to Vote

Is your patient capable of making judgments for the purpose of complying with the provisions of the Electoral Act 1907 relating to compulsory voting?

Yes, capable No, incapable Unsure

Attendance at Tribunal Hearings

The Tribunal is required to seek and obtain your patient’s view at the hearing and they are expected to attend.

Please indicate whether attending would be adverse to your patient’s health and well-being:

Yes No Unsure

If yes, please provide details:

Communication

Your patient:

speaks English

speaks another language (please specify):

uses sign language/other (please specify):

has difficulty in communicating (please specify):

is unable to communicate.

Declaration

I declare that the information provided is true to the best of my knowledge and belief and the opinions expressed are within my area of expertise.