Capacity Assessment Screening Tool

If there is an immediate risk, do not complete this form.

Instead it is recommended to contact one or more of the following:

Public Guardian and Trustee 1-800-891-0504
Law Society of Ontario Referral 1-855-947-5255
Ministry of the Attorney General Capacity Assessment Office 1-800-366-0335
Independent Legal Counsel

This form provides the necessary information to initiate the screening process for a capacity assessment. All information provided will be reviewed by a clinician and you will be contacted with the next steps.

Personal Details

Requestor (You)

Legal Name

Date of Birth

Address

Phone

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General

I am seeking an assessment for:

Property/Financial Capacity Personal Care Capacity Both Property and Personal Care Capacities Testamentary Capacity Other

Why do you believe a capacity assessment is required?

Include any specific problems faced by the person, any risks they face, etc.

Has a lawyer been assisting you?

Yes

Lawyer's Name & Phone:

Select all options/avenues you have already explored:

Power of Attorney

Trusteeship

Medical Assessment

Guardianship Investigations

Legal Counsel

Court Application(s)

Accomodation Requirements

Include any details you think would help (e.g. wears glasses, uses a walker/cane/wheelchair, has trouble in the morning/evening, uses hearing aids, etc.)

Describe any recent medical, financial or social changes in the person's life?

Examples: Death of spouse or caregiver, sudden illness or accident, inheritance, significant financial gain/loss, etc.

Describe any urgency to this request:

Include details about significant financial, social, medical or other risks

Records

Power of Attorney

Has the person signed a Power of Attorney for Property?

Yes No Unsure

Do you have a copy of the Power of Attorney?

Yes No

Has the person signed a Power of Attorney for Personal Care?

Yes No Unsure

Do you have a copy of the Power of Attorney?

Yes No

Can you obtain a copy of the Power of Attorney?

Yes No Unsure

Power of Attorney Forms Please upload one or both Power of Attorney forms

Add file

Please upload a file

Financial

Do you have copies of the financial records for this person?

Yes No

Can you obtain copies of financial records?

Yes No Unsure

Financial Records Please upload any statements or records you have

Add file

Please upload a file

Medical

Do you have copies of medical records?

Yes No

Can you obtain copies of medical records?

Yes No Unsure

Medical Records Please upload any medical records you have

Add file

Please upload a file

Assessment History

Has this person ever been assessed for capacity?

Yes No Unsure

Do you have a copy of the assessment report(s)?

Yes No

Capacity Assessments Please upload any the report(s)

Add file

Please upload a file

Add additional assessment

Medical History

Is this person currently admitted to a hospital or medical facility?

Yes No Unsure

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Has this person been diagnosed with a medical or psychiatric condition?

Yes No Unsure

Add additional diagnosis

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Agreements

Responsibility for Fees

I understand the requestor is the individual/organization responsibile for all fees related to this request. If the request is being made by an organization, I confirm I am authorized to make this request on their behalf.

Rights of the Person to be Assessed

Important Note: s. 78 of the Substitute Decisions Act, 1992, governs the rights of any person to be assessed. This includes:

A right to know the purpose of the assessment
A right to know the significance and effect of a finding of capacity or incapacity
A right to refuse to be assessed

Assessors are required to inform the person to be assessed of these rights prior to the assessment. The person must assent to the assessment, and may indicate refusal up and until the moment the report is filed according to the procedural guidelines.

Exceptions apply if the assessment is conducted under a court-order, subject to s. 79 of the Substitute Decisions Act, 1992, or under a specific provision within a valid Power of Attorney for Personal Care which authorizes the use of force to permit the assessment.

I understand that the person to be assessed has the right to refuse. As a result, I accept that, as the requestor, I will be responsible for payment of the assessment fee if the person to be assessed does not assent once the assessor has arrived at the interview location or at any point prior to the report being filed. I accept that if they refuse, no determination on capacity can be provided.

By clicking submit, I attest that all information on this form is accurate, to the best of my knowledge.

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