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Office of the Vulnerable Persons’ Commissioner

Application for the Appointment of aSubstitute Decision Maker

Under The Vulnerable Persons Living with a Mental Disability A t, certain requirements must be metin order for a substitute decision maker to be appointed for an individual. T ese requirements are addressed by t e questions asked in t is application form. Please answer all questions in as muc detail as possible.

Please refer to t e Guide to Completing the Substitute De ision Maker Application for furt er explanation and direction in completing t is application.

If you need more space to complete your answers, please attac a separate page and include t e section numbers (ex: 1.2, A, i).

Ce formulaire de demande e iste également en français. Composez le 204-945-5039 ou le 1 800 757-9857(sans frais).

Part 1 InformatIon about the Person for Whom a substItute DecIsIon maker Is requesteD – calleD “the InDI IDual” In thIs aPPlIcatIon

1.1 About the individual

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Last name First name Middle name

Birth date (mm/dd/yyyy) Gender

______________________________________________________________________ o M o F

Address (street number, street name, town/city, province, postal code)

Mailing address, if different from above (street number, street name, town/city, province, postal code)

Type of residence (family ome, community residence, foster ome, independent Living there since? living wit support, personal care ome, developmental centre, etc.)

Who is the main contact person at the residence? Name Title P one number

( )

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List ways in which the individual is involved in the community (day programs/work/sc ool)

1. Name of program/work/sc ool:

Main contact person at t e program/work/sc ool (name, title, p one number)

Attending since?

2. Name of program/work/sc ool:

Main contact person at t e program/work/sc ool (name, title, p one number)

Attending since?

3. Name of program/work/sc ool:

Main contact person at t e program/work/sc ool (name, title, p one number)

Attending since?

1.2 Is the individual a vulnerable person? (See under Se tion C – part 1, subse tion 1.2 of guide)

a) An adult living ith a mental disability (“Mental disability” excludes a mental disability due exclusively to a mental or psyc iatric disorder defned under The Mental Health A t.)

The following are the criteria that defne “mental disability”. E plain why you believe the individual is:

i) a person with Signifcant Intellectual Impairment

ii) a person with Impaired Adaptive Behaviour

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iii) a person with a disability Manifested Prior to Age 18

b) Assistance meeting basic needs Describe what kind of assistance the individual needs to meet his or her basic needs for:

Personal care (ex: elp wit medical issues, personal ygiene, domestic tasks, etc.)

Property (ex: elp wit money management)

1.3 Supporting documents (See under Se tion C – part 1, subse tion 1.3 of guide)

Attach documents to support the information provided in questions 1.2 and 6.1.E amples of supporting documents include:

evaluation report(s) from psychologists, psychiatrists, pediatricians, school clinicians (speech pathologists,occupational therapists), etc. medical records diagnosing a specifc developmental disorder, signifcant cognitive impairment or mental disability supported living level of care form supported living personal fnancial plan individual plan (IP) or individual education plan (IEP) behaviour support plan and/or other related information e isting social history reports other

Vulnerable Persons’ Commissioners’ Offce (VPCO) use only

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1.4 Individual’s social orker/case co-ordinator (if kno n)

Name __________________________________________________________________________

Mailing address ___________________________________________________________________

( ) ( )P one number ___________________________________ Fax_____________________________

1.5 Individual’s nearest relative (See under Se tion C – part 1, subse tion 1.5 of guide)

Name Relations ip to individual

Mailing address

( )P one number ________________________________________________________________________________

Part 2 InformatIon about the aPPlIcant

Name Relations ip to individual

Mailing address

P one number ________________________________________________________________________________( )

Part 3 reason(s) for the aPPlIcatIon (See under Se tion C – part 3 of guide)

3.1 What are the circumstances that give you reason to believe that a substitutedecision maker is needed at this time?

Part 4 InformatIon about the InDI IDual’s suPPort netWork (See under Se tion C – part 4 of guide)

4.1 People ho provide advice, support and guidance to the individual

a) Family members 1. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

P one number _______________________________ Relations ip___________________________________ ( )

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Nature and frequency of involvement __________________________________________________________

2. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

( )P one number _______________________________ Relations ip___________________________________

Nature and frequency of involvement __________________________________________________________

3. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

( )P one number _______________________________ Relations ip___________________________________

Nature and frequency of involvement __________________________________________________________

4. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

( )P one number _______________________________ Relations ip___________________________________

Nature and frequency of involvement __________________________________________________________

b) Others chosen by the individual (friends, paid service/care providers, advocates, etc.)

1. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

P one number _______________________________ Relations ip___________________________________ ( )

Nature and frequency of involvement __________________________________________________________

2. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

P one number _______________________________ Relations ip___________________________________ ( )

Nature and frequency of involvement __________________________________________________________

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3. Name _____________________________________________________________________________________

Mailing address _____________________________________________________________________________

( )P one number _______________________________ Relations ip___________________________________

Nature and frequency of involvement __________________________________________________________

1. Name Relations ip P one number

( )

Mailing address

2. Name Relations ip P one number ( )

Mailing address

4.2 Service/care provider (if not mentioned above)

Part 5 InformatIon about the ProPoseD substItute DecIsIon maker(s) (sDm) (See under Se tion C – part 5 of guide)

5.1 Sole substitute decision maker(s) (SDM)

1. Name Relations ip

______________________________________________________________________ ___________________

Mailing address P one number

( )______________________________________________________________________ ___________________

SDM forPersonal care Property

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2. Name Relations ip

______________________________________________________________________ ___________________

Mailing address P one number

( )______________________________________________________________________ ___________________ SDM forPersonal care Property

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5.2 Joint substitute decision maker(s) (SDM)

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1. Name Relations ip

Mailing address P one number

( )

SDM forPersonal care Property

2. Name Relations ip

Mailing address P one number

( )

SDM forPersonal care Property

3. Name Relations ip

Mailing address P one number

( )

SDM forPersonal care Property

5.3 Alternate substitute decision maker(s) (ASDM)

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1. Name Relations ip

Mailing address P one number

( )

ASDM forPersonal care Property

2. Name Relations ip

Mailing address P one number

( )

ASDM forPersonal care Property

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Notes: • “Sc edule A” must be completed if applying to be a substitute decision maker for property. • “Sc edule B” must be completed by all proposed substitute decision makers. • A Criminal Record C eck, C ild Abuse Registry C eck, and an Adult Abuse Registry C eck is required by all

proposed substitute decision makers – see “Sc edule C” • If a substitute decision maker is not identifed, T e Public Trustee will be appointed.

Part 6 DecIsIon(s) to be maDe (Appli ants should read under Se tion C – part 6 of guide before ompleting this se tion)

6.1 Decision(s) to be made

Describe below the decision(s) or issue(s) the individual:

• is facing now and/or e pected to face in the reasonably foreseeable futureAND

• is not able to make even with the involvement of his or her support network

A person is considered unable to make a decision w en s e/ e is not able to understand information relevant to making a decision about personal care or t e management of property; or is not able to appreciate t e reasonably foreseeable consequences of a decision or lack of one.

What decision(s) or issue(s) is/are there in the area of personal care?

What decision(s) or issue(s) is/are there in the area of property?

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Part 7 other InformatIon requIreD

7.1 Considering the decision(s) to be made in Part 6, what should be the length of time of the substitute decision maker appointment? (See under Se tion C – part 7, subse tion 7.1 of guide)

7.2 Is there currently a substitute decision maker appointed for the individual? Yes No

Has there been in the past? Yes No

7.3 Does the individual have a committee appointed by the Court of Queen’s Bench or an Order of Committeeship under The Mental Health Act? (See under Se tion C – part 7, subse tion 7.3 of guide)

Yes No

7.4 Describe any physical or communication arrangements that will be needed for the individual,the proposed substitute decision maker and/or other parties should they need to participate at a hearing panel. (See under Se tion C – part 7, subse tion 7.4 of guide)

7.5 Do you have further information or comments that would be helpful to the commissioner in considering this application for appointment of a substitute decision maker?

sIgnature of aPPlIcant

Signature Date

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Have you: completed t e application in full

enclosed supporting documents noted on page 3

completed “Sc edule A” – real and personal property (if applying for property)

completed “Sc edule B” – consent form signed by t e proposed substitute decision maker(s)

enclosed t e Criminal Record C eck(s), C ild Abuse Registry C eck(s), and AdultAbuse Registry C eck for all proposed substitute decision makers – See “Sc edule C”

Note: Incomplete application packages will take longer to process.

Send completed applications and documents to: Office of the Vulnerable Persons’ Commissioner 315-258 Portage Avenue Winnipeg, Manitoba R3C 0B6

Telephone: 204-945-5039 Toll Free: 1-800-757-9857 Fax: 204-948-3713

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for communIty ser Ice Worker/socIal Worker use only

For VPCO information gathering purposes, if you directly assisted the applicant in completing this application, please complete the following:

1) Do you believe a substitute decision maker is warranted for this individual?Yes No

Why?

2) Do you believe the proposed substitute decision maker(s) is suitable, capable and able to perform the duties of a substitute decision maker? Yes No

Why?

3) Do you have further information or comments that would be helpful to the commissioner in this application for appointment of a substitute decision maker?

sIgnature of csW/socIal Worker

Signature of CSW/Social Worker Date

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SCHEDULE A REAL AND PERSONAL PROPERTY (IF KNOWN)

OF [person for whom application is made] __________________________________________

1. REAL AND PERSONAL PROPERTY

Bank/Investment accounts [place of deposit, balance of each account]:

Stocks and bonds [estimate of value, place of deposit]:

R.R.S.Ps [amount, place of deposit]:

Real estate [legal descriptions of civic addresses]:

Vehicles [make, model, year]:

Life insurance policies [cash surrender values, names of insurers]:

Funeral plans [cash value, place of deposit]:

Monies owed to [estimate of amounts, names of debtors]

Other (specify)

2. DEBTS: Liability: Personal/Property loans

Creditor ________________________ Balance owing _______________________

Liability: Credit cards

Creditor ________________________ Balance owing _______________________

Liability: Other (specify)

Creditor ________________________ Balance owing _______________________

http:R.R.S.Ps

___________________________________ ______________________________

3. INCOME:

Source _____________________ Amount ___________ Frequency _______________

Source _____________________ Amount ___________ Frequency _______________

4. EXPENSES:

Source _____________________ Amount ___________ Frequency _______________

Source _____________________ Amount ___________ Frequency _______________

Signature Date

SCHEDULE B

Consent Form for Considerationof Appointment as Substitute Decision Maker

I/We, [name(s) of proposed substitute decision maker(s)]

do hereby consent to my/our appointment as substitute decision maker(s) for

[name of person for whom substitute decision maker is requested]

in respect of whom decision-making power is sought in the areas of o personal careo property

I/We understand that my/our appointment as a substitute decision maker is conditional upon the results of a Criminal Record Check (including the Vulnerable Sector Search), a Child Abuse Registry Check and an Adult Abuse Registry Check and agree to apply for these checks and to submit these records to the Vulnerable Persons’ Commissioner.

I/We understand that my/our appointment will require me/us to comply with the duties of a substitute decision maker as set out in The Vulnerable Persons Living with a Mental Disability Act and any terms and conditions as directed by the Vulnerable Persons’ Commissioner.

I/We further understand that as a substitute decision maker for property I/we will be required to file within six months of my/our appointment a true inventory and account of the vulnerable person’s property, debts and liabilities which would be under my/our power, and yearly thereafter, an annual accounting of the property, debts, liabilities, receipts and disbursements of the vulnerable person, unless I am/we are directed otherwise by the Vulnerable Persons’ Commissioner.

I/We further understand that as a substitute decision maker for property I/we may be required to provide a bond or other security which would be equal to the amount of the sworn value of the property under my/our power as the substitute decision maker(s), as directed by the Vulnerable Persons’ Commissioner.

*Signature of proposed substitute decision maker Date

*Signature of proposed substitute decision maker Date

* Not required for The Public Trustee

SCHEDULE C

CRIMINAL RECORD, CHILD ABUSE REGISTRY AND ADULT ABUSE REGISTRY CHECKS

As part of the Application for Appointment of a Substitute Decision Maker, a proposed substitute decision maker must obtain a Criminal Record Check, a Child Abuse Registry Check, and an Adult Abuse Registry Check. The results of these Checks will be sent to you directly. It is your responsibility to then attach them to the Application and/or to send them to the Office of the Vulnerable Persons’ Commissioner.

CRIMINAL RECORD CHECK

A Criminal Record Search Certificate can be obtained from the local city or municipal police department, or in rural areas, from the local Royal Canadian Mounted Police detachment. The Criminal Record Check must include the Vulnerable Sectors Search. When returning the completed form to the police/RCMP, two pieces of identification and an associated fee payment is normally required. The police office will provide the Criminal Record results to you. Questions regarding this process should be directed to your local city, or municipal police department or local RCMP detachment (rural areas only). For Winnipeg residents, information can be obtained by calling 204-986-6074 or by going online at www.winnipeg.ca/police.

CHILD ABUSE REGISTRY CHECK

A Child Abuse Registry Check can be obtained by completing the Child Abuse Registry Check Request application form and sending it to the Child Abuse Registry Office. The application forms are available by contacting the Child Protection Office – contact information below or on-line at: www.gov.mb.ca/fs/childfam/child_abuse_registry_form.html. Whenreturning the completed form to the Child Abuse Registry Office, a verified photocopy of two pieces of valid identification and an associated fee payment is normally required. Please refer to Part 3 of Child Abuse Registry Check form for payment details. The Child Abuse Registry office will provide the Registry results to you.

For more information about the Child Abuse Registry Check process or to mail in your application, contact:

Child Protection 2 - 777 Portage Avenue Winnipeg, MB R3G 0N3 Phone: 204-945-6967 Toll free: 1-800-282-8069 Fax: 204-948-2222 Email: car@gov.mb.caWebsite: www.gov.mb.ca/fs/childfam/child_abuse_registry.html.

ADULT ABUSE REGISTRY CHECK

An Adult Abuse Registry Check form can be obtained by contacting the Office of the Vulnerable Persons’ Commissioner at 204-945-5039 or 1-800-757-9857; Fax number: 204-948-3713; email: vpco@gov.mb.ca. The form and instructions on how to complete it will then be mailed to you.

http://www.gov.mb.ca/fs/childfam/child_abuse_registry_form.htmlmailto:car@gov.mb.camailto:vpco@gov.mb.ca

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Once completed, it is to be sent the Adult Abuse Registrar at the address below. When sending the form to the Adult Abuse Registrar, a verified photocopy of two pieces of valid identification is required. The Check is fee-exempt. The Adult Abuse Registry office will provide the Registry results to you.

Adult Abuse Registry Check Form Mailing Address:

The Adult Abuse Registrar Adult Abuse Registry Unit 2 - 777 Portage Avenue Winnipeg, MB R3G 0N3 204-945-4934

IMPORTANT

When you receive the results of the above Checks, it is your responsibility as the proposed substitute decision maker to attach a copy of each of the Checks to the substitute decision maker application and/or to send them to the Office of the Vulnerable Persons’ Commissioner.

Protection of Privacy The personal information that you are requested to provide is being collected under the authority of The Vulnerable Persons Living with a Mental Disability Act (the Act). It is being collected to administer the Act and assist in the determination of your eligibility to serve as a substitute decision maker.

This personal information is protected by the protection of privacy provisions of The Freedom of Information and Protection of Privacy Act, and under The Personal Health Information Act.

If you have any questions about the collection of personal information, please contact:

Access and Privacy Coordinator Department of Families 205-114 Garry StreetWinnipeg, MB R3C 4V4Telephone: 204-945-2013

appt_sdm.pdfschedule_a_new.pdfSCHEDULE A

sb_consent_appt_sdm.pdfschedule_c.pdfprotection_privacy.pdfProtection of Privacy

Last name: Text52: Text53: Birth date mmddyyyy: gender: Offstreet number street name towncity province postal code: Mailing address if different from above street number street name towncity province postal code: living with support personal care home developmental centre etc: Text2: Text54: Text55: Text56: Text57: Name of programworkschool: Main contact person at the programworkschool name title phone number: Attending since: Name of programworkschool_2: Main contact person at the programworkschool name title phone number_2: Attending since_2: Name of programworkschool_3: Main contact person at the programworkschool name title phone number_3: Attending since_3: Text60: Text61: Text62: Text63: Text64: Check Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72: YesName: Mailing address: Text73: Text74: Text75: Text76: Mailing address_2: Text77: undefined_3: Text144: Text145: Mailing address_3: Text146: undefined_5: Text83: Text147: Text81: 1 Name: Mailing address_4: Text78: Text82: Relationship: Text85: Text86: 2 Name: Mailing address_5: Text87: Text88: Relationship_2: Nature and frequency of involvement 1: Nature and frequency of involvement 2: Text89: Text90: Text91: Text92: Text93: Text94: Text95: Text96: Text97: Text98: Text99: Text100: Text101: Text102: 1 Name_2: Mailing address_8: Text103: Text104: Relationship_5: Nature and frequency of involvement 1_4: Nature and frequency of involvement 2_4: 2 Name_2: Mailing address_9: Text105: Text106: Relationship_6: Nature and frequency of involvement_2: Text107: 3 Name_2: Mailing address_10: Text108: Text109: undefined_7: Relationship_7: Nature and frequency of involvement_3: Text110: Text111: Text112: Text113: Mailing address_11: Text114: Text115: Text116: Text117: Mailing address_12: 1 Name_3: Text118: Text119: Text120: Text121: Personal care: Check Box27: OffCheck Box27b: Off1 Name_3a: Text122a: Text119a: Text120a: Text121a: Personal carea: Check Boxaa: OffCheck Box27bbb: OffMailing address_13: Text124: Text125: Text127: Text126: Personal care_3: Check Box1a: OffCheck Box27 1b: OffMailing address_13a: Text124a: Text125a: Text127a: Text126a: Personal care_3a: Check Box28a: OffCheck Box29: OffMailing address_13b: Text124b: Text125b: Text127b: Text126b: Personal care_3b: Check Box30: OffCheck Box31: OffMailing address_13c: Text124c: Text125c: Text127c: Text126c: Personal care_3c: Check Box 1g: OffCheck Box27 1h: OffMailing address_13d: Text124d: Text125d: Text127d: Text126d: Personal care_3d: Check Box 1j: OffCheck Box27 1k: OffText133: Text134: decision maker appointment See under Section C part 7 subsection 71 of guide: SDM: Offpast: Offcommittee: OffText141: Text142: appDate: completed the application in full: Offenclosed supporting documents noted on page 3: Offcompleted Schedule A real and personal property if applying for property: Offcompleted Schedule B consent form signed by the proposed substitute decision: Offenclosed the Criminal Record Checks and Child Abuse Registry Checks for all: Offwarranted: OffWhy: duties: OffWhy_2: Text143: Signature of CSWSocial Worker: socWorkerDate: person_application: BankInvestment accounts place of deposit balance of each account: Stocks and bonds estimate of value place of deposit: RRSPs amount place of deposit: Real estate legal descriptions of civic addresses: Vehicles make model year: Life insurance policies cash surrender values names of insurers: Funeral plans cash value place of deposit: Monies owed to estimate of amounts names of debtors: Other specify: Liability PersonalProperty loans: balLoans: Liability Credit cards: balCredit: Liability Other specify: balOther: income_source1: income_amount1: income_freq1: income_source2: income_amount2: income_freq2: expenses_source1: expenses_amount1: Frequency_3: expenses_source2: expenses_amount2: Frequency_4: Date: subDecisionMakers1: subDecisionMakers2: name of person for whom substitute decision maker is requested: chkPersonalCare: OffchkProperty: OffschedBDate: schedBDate2: RESET: