Adult Guardianship and Trusteeship (Ministerial) Regulation

(Consolidated up to 43/2026) ALBERTA REGULATION AR 224/2009 Adult Guardianship and Trusteeship Act ADULT GUARDIANSHIP AND TRUSTEESHIP (MINISTERIAL) REGULATION Table of Contents 1 Definitions 2 Persons eligible to be supporter 3 Supported decision‑making authorizations 4 Powers and responsibilities of supporters 5 Validity of supported decision‑making authorizations 6 Standards of conduct for capacity assessors 7 Forms 9 Coming into force Schedule Definitions 1 In this Regulation, “Act” means the Adult Guardianship and Trusteeship Act . Persons eligible to be supporter 2 An adult may appoint as a supporter a person who (a) consents to act as a supporter, (b) is not an assisted adult or represented adult, and (c) does not have (i) a personal directive that is in effect, or (ii) an enduring power of attorney that is in effect because of the incapacity of the person. Supported decision‑making authorizations 3 (1) A supported decision‑making authorization must be (a) signed by the adult making the authorization or a person acting on behalf of the adult under subsection (4) in the presence of the witness referred to in clause (b), and (b) witnessed by an adult who (i) is not named as a supporter in the authorization, and (ii) did not sign the authorization on behalf of the adult. (2) A supported decision‑making authorization must contain the consent of each person appointed as a supporter in the authorization. (3) An amendment to or termination of a supported decision‑making authorization must be (a) in writing, (b) signed and dated by the supported adult or by a person acting on the supported adult’s behalf under subsection (4), and (c) witnessed by an adult who (i) is not appointed as a supporter in the authorization, and (ii) did not sign the authorization on behalf of the adult. (4) If an adult who is making, amending or terminating a supported decision‑making authorization is not physically able to sign the authorization, amendment or termination, an adult who is not named as a supporter in the supported decision‑making authorization may, at the direction of the adult, sign the authorization, amendment or termination on behalf of the adult. (5) A person who signs a supported decision‑making authorization or an amendment to or termination of a supported decision‑making authorization on behalf of an adult shall, in the presence of the adult and the witness, sign the person’s own name and indicate that the person has signed on behalf of the adult. AR 224/2009 s3;43/2026 Powers and responsibilities of supporters 4 (1) A supporter shall exercise the supporter’s powers and responsibilities (a) in the supported adult’s best interests, (b) diligently, and (c) in good faith. (2) A supporter shall keep a written record of all decisions that the supported adult makes or communicates by or with the assistance of the supporter. (3) If a supporter accesses, collects or obtains personal information about the supported adult from a public body, custodian or organization, the supporter shall keep a written record of (a) the reason for accessing, collecting or obtaining the personal information, (b) the name of the public body, custodian or organization that provides access to the personal information or from whom the personal information is collected or obtained, (c) a brief description of the personal information that is accessed, collected or obtained, and (d) the date on which the personal information is accessed, collected or obtained. (4) If a supporter uses or discloses personal information referred to in subsection (3), the supporter shall keep a written record of (a) the reason for using or disclosing the personal information, (b) a brief description of the personal information that is used or disclosed, (c) the name of any person to whom the personal information is disclosed, and (d) the date on which the personal information is used or disclosed. (5) A supporter shall retain a written record referred to in subsections (2) to (4) for at least 2 years after the day on which the supporter ceases to have authority under the supported decision‑making authorization. Validity of supported decision‑making authorizations 5 (1) If a supported decision‑making authorization purports to give powers to a supporter respecting the financial matters of the supported adult, the supported decision‑making authorization is not valid to the extent that it purports to give a supporter those powers. (2) A supported decision‑making authorization is not valid unless (a) it is in Form 1 as set out in the Schedule, and (b) it includes a termination of any previous supported decision‑making authorization. Standards of conduct for capacity assessors 6 A person who is designated as a capacity assessor shall comply with the following standards: (a) when conducting a capacity assessment, a capacity assessor shall (i) comply with the guidelines for conducting capacity assessments established by the Minister; (ii) exercise care and diligence; (iii) act in good faith; (iv) have regard to the fact that (A) the adult who is undergoing the capacity assessment is presumed to have the capacity to make decisions until the contrary is determined, and (B) the adult who is undergoing the capacity assessment is entitled to communicate by any means that enables the adult to be understood, and the means by which the adult communicates is not relevant to a determination of whether the adult has the capacity to make decisions; (b) a capacity assessor shall maintain professional competency to conduct capacity assessments. AR 224/2009 s6;43/2026 Forms 7 (1) The form for a supported decision‑making authorization for the purposes of section 4(3) of the Act is set out in Form 1 in the Schedule. (2) A termination of a supported decision‑making authorization for the purposes of section 7(2) of the Act must be in the form set out in (a) item 1 of Form 1 in the Schedule, or (b) Form 2 in the Schedule. (3) The form for a capacity assessment report in respect of an application for a co‑decision‑making order is set out in Form 3 in the Schedule. (4) The form for a capacity assessment report in respect of an application for a guardianship order or trusteeship order is set out in Form 4 in the Schedule. (5) The form for a complaint for the purposes of section 75 of the Act is set out in Form 5 in the Schedule. (6) An assessment of an adult’s capacity to make a decision respecting the adult’s health care or the adult’s temporary admission to or discharge from a residential facility, for the purposes of section 87 of the Act, must be in the form set out in Part 1 of Form 6 in the Schedule. (6.1) An assessment of an adult’s capacity to make decisions about financial matters, for the purposes of section 100.2 of the Act, must be in the form set out in Part 1 of Form 6 in the Schedule. (7) A declaration of a specific decision maker for the purposes of section 90 of the Act must be in the form set out in Part 2 of Form 6 in the Schedule. (8) A written record that a health care provider is required to keep for the purposes of section 91 of the Act must be in the form set out in Part 3 of Form 6 in the Schedule. (9) Repealed AR 47/2010 s2. (10) The form for a capacity assessment report for the purposes of sections 96 and 100.5 of the Act is set out in Form 10 in the Schedule. (11) A notice of a financial decision, for the purposes of section 100.6 of the Act, must be in the form set out in Form 11 in the Schedule. AR 224/2009 s7;47/2010;43/2026 8 Repealed AR 11/2019 s2. Coming into force 9 This Regulation comes into force on the coming into force of the Adult Guardianship and Trusteeship Act . Schedule Form 1 Supported Decision‑making Authorization Adult Guardianship and Trusteeship Act (Section 4(3)) I, (supported adult) , am a resident of Alberta and make this supported decision‑making authorization. 1 Termination of previous supported decision ‑ making authorization I terminate all previous supported decision‑making authorizations made by me. (initials of supported adult and witness) 2 Appointment of supporter(s) Under section 4(1) of the Adult Guardianship and Trusteeship Act , a maximum of 3 supporters may be appointed. I appoint the following person(s) as my supporter(s): (a) (name of supporter) ; (initials of supported adult and witness) (b) (name of supporter) ; (initials of supported adult and witness) (c) (name of supporter) ; (initials of supported adult and witness) 3 Decisions respecting personal matters for which supporter has authority My supporter(s) has (have) authority in respect of decisions to be made by me relating to the following personal matters (check all relevant boxes and initial at the end): □ health care (initials of supported adult and witness) □ where to live, either permanently or temporarily (initials of supported adult and witness) □ with whom to associate (initials of supported adult and witness) □ participation in social activities (initials of supported adult and witness) □ participation in educational, vocational or other training (initials of supported adult and witness) □ participation in employment activities (initials of supported adult and witness) □ legal matters that do not relate primarily to financial matters (initials of supported adult and witness) □ other:________________________________________________ ( initials of supported adult and witness) 4 Authority of supporter(s) NOTE: If (a) is checked below, a supporter may access, collect or obtain only that personal information about the supported adult that is relevant to the decision the adult is making. A supporter may not access financial information about the supported adult. A supporter may use and disclose the personal information only for the purpose of exercising the supporter’s authority under this authorization and must take reasonable care to ensure the adult’s personal information is secure. A supporter must keep a written record of any personal information about the supported adult that the supporter accesses, collects or obtains or that the supporter uses or discloses. I give my supporter(s) the authority to (check the relevant boxes and initial at the end): □ (a) access, collect or obtain or assist me in accessing, collecting or obtaining from any person any information that is relevant to the decision(s) related to the personal matters specified in item 3 and to assist me in understanding the information; (initials of supported adult and witness) □ (b) assist me in making the decision(s) related to the personal matters specified in item 3; (initials of supported adult and witness) □ (c) communicate or assist me in communicating the decision(s) related to the personal matters specified in item 3 to other persons. (initials of supported adult and witness) 5 Effective dates of supported decision ‑ making authorization This supported decision‑making authorization has effect from (start date) to (end date)* . (*optional) 6 Consent of supporters I consent to act as a supporter: ___________________ ___________ _____________________ (printed name of supporter) (date) (signature of supporter) ___________________ ___________ _____________________ (printed name of supporter) (date) (signature of supporter) ___________________ ___________ _____________________ (printed name of supporter) (date) (signature of supporter) 7 Signature Signed by me in the presence of (name of witness) at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________________ (signature of supported adult, or a person acting on behalf of the supported adult, in the presence of the witness) ________________________________________________ (signature of witness in the presence of the supported adult) ________________________________________________ (printed name and address of witness) Note: The witness should also initial the provisions initialled by the supported adult. The following persons must not witness a supported decision‑making authorization: • a person named in the authorization as a supporter; • a person who signs the authorization on behalf of the supported adult. Form 2 Termination of Supported Decision‑making Authorization Adult Guardianship and Trusteeship Act (Section 7(2)) I, (supported adult) , terminate the supported decision‑making authorization that I made on (date) . Signed by me in the presence of (name of witness) at (location) in the Province of Alberta this (day) of (month) , (year) . _________________________________________ (signature of supported adult, or a person acting on behalf of the supported adult, in the presence of the witness) ________________________________________________ (signature of witness in the presence of the supported adult) ________________________________ (printed name and address of witness) ________________________________ The following persons must not witness a termination of a supported decision‑making authorization: • a person named in the authorization as a supporter ; • a person who signs the authorization on behalf of the supported adult. Form 3 Capacity Assessment Report (Co‑decision-making) Adult Guardianship and Trusteeship Act (Sections 13, 102) This form of capacity assessment report is to be used in respect of an application for a co‑decision‑making order under the Adult Guardianship and Trusteeship Act . “capacity” means, in respect of the making of a decision about a matter, the ability to understand the information that is relevant to the decision and to appreciate the reasonably foreseeable consequences of (a) a decision, and (b) a failure to make a decision; “significantly impaired”, in respect of an adult’s capacity to make decisions, means that the adult’s cognitive and adaptive abilities (a) are substantially limited as the result of an impairment, including, without limitation, a developmental disability, an organic, degenerative or neurological disease or disorder, an acquired brain injury or a chronic mental illness, and (b) are not so substantially limited that the adult would not have the capacity to make decisions with appropriate guidance and support. 1 . I, (name of physician or psychologist) , am a registered member of the (name of the physician’s or psychologist’s professional college) . OR If the capacity assessor is not a physician or registered psychologist, the capacity assessor must complete the following: I, (name of capacity assessor) , am currently designated as a capacity assessor under the Adult Guardianship and Trusteeship Act . My designation is dated (day/month/year) . I was designated as a capacity assessor under the following Ministerial Order: (Ministerial Order number) . 2 . This capacity assessment report is about (name of the adult) (the “adult”) of (address of the adult) , whose date of birth is (date of birth of the adult) . 3. The reason(s) or circumstances leading up to the request for this capacity assessment are______________________________________ _________________________________________________________ 4. I have obtained confirmation that a medical evaluation of the adult was conducted by (name of physician or nurse practitioner) on (day/month/year) (within the 3‑month period immediately preceding the capacity assessment) and that the results of the medical evaluation did not indicate that the adult was suffering from a reversible temporary medical condition that appeared likely to have a significant impact on the adult’s capacity to make a decision about a personal matter. Comments: _________________________________________________ 5. The adult has been diagnosed by a physician as having the following medical condition(s) that is (are) relevant to this capacity assessment: Diagnosis: __________________________________________________ Name of physician: ___________________________________________ Date of diagnosis: (day/month/year) Comments: _____________________________________________ 6. Prior to conducting a capacity assessment of (name of the adult) I met with the adult and, unless the level of consciousness of the adult was such that the adult was non ‑ responsive, I explained to the adult (a) the purpose and nature of the capacity assessment, (b) that the adult has the right to refuse (i) to undergo the capacity assessment, or (ii) to continue with the capacity assessment at any point during the capacity assessment, (c) that the adult has the right to (i) have a person present to assist the adult in feeling comfortable and relaxed when undergoing the capacity assessment, and (ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate the adult’s capacity during the capacity assessment, (d) the significance and effect of a finding that the adult’s capacity to make decisions respecting a personal matter is significantly impaired, and (e) that if a person who is present to assist the adult during the capacity assessment is, in my opinion, interfering with the capacity assessment, the person may be asked to leave. Comments:__________________________________________________ 7. The adult □ (a) appears to be capable of understanding the purpose of the capacity assessment, or □ (b) does not appear to be capable of understanding the purpose of the capacity assessment. 8. The adult has □ (a) refused to undergo or to continue with the capacity assessment, or □ (b) not refused to undergo or to continue with the capacity assessment. If (a) has been checked above □ (a) a capacity assessment was not conducted, or □ (b) the capacity assessment was discontinued. Comments: _____________________________________________ 9. The adult chose to □ have the following person present to assist the adult in feeling comfortable and relaxed during the capacity assessment: (name of person present and relationship to the adult) □ use the following assistive device or had the following person present to assist with communication during the capacity assessment: (device used or name of person present and role, e.g. language interpreter) 10. I asked the adult if there have been any significant changes recently in the adult’s beliefs and values related to making decisions about the personal matter(s) identified in item 11 and the adult informed me that □ (a) there have been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s), or □ (b) there have not been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s). Comments: _____________________________________________ 11. I assessed the capacity of the adult to make decisions about the following personal matters and my opinion respecting the adult’s capacity to make decisions about those matters is indicated in the first or second column below: Adult has capacity Capacity of adult is significantly impaired Matter □ □ the adult’s health care □ □ where, with whom and under what conditions the adult is to live, either permanently or temporarily □ □ with whom the adult may associate □ □ the adult’s participation in social activities □ □ the adult’s participation in any educational, vocational or other training □ □ the adult’s employment □ □ the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult □ □ other (specify) Note: Draw a line through any matters in respect of which you have not assessed the adult’s capacity. The reasons for my opinion are as follows: (set out the reasons) In forming my opinion about the adult’s capacity to make decisions about the specified personal matter(s), (a) I considered the adult’s ability to understand the information that is relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision and a failure to make a decision about the personal matter(s), and (b) I took into account (i) whether the adult has the ability to retain information that is relevant to decisions about the personal matter(s), and (ii) the following additional factors, if any: (specify) . Comments: _____________________________________________ 12 . In my opinion, the adult has the capacity to consent to (a) the appointment of any individual who is proposed to be appointed as a co‑decision‑maker, and (b) a co‑decision‑making order. 13. If in item 11 I have stated that in my opinion the capacity of the adult to make decisions about one or more personal matters is significantly impaired, I have considered whether the adult is likely to regain some or all of the adult’s capacity to make decisions about the matter(s) and I believe that the adult □ (a) is likely to regain some or all of the capacity to make decisions about the matter(s) and I recommend that another capacity assessment of the adult be conducted by no later than (day/month/year) , or Comments:__________________________________________________ □ (b) is not likely to regain some or all of the capacity to make decisions about the matter(s). Comments:______________________­___________________________ 14. I have attached more detailed information respecting the capacity assessment. □ Yes. I have attached the following documents: ___________ ______________________________________________ □ No. Dated at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________ (print name of physician, psychologist or capacity assessor who conducted the capacity assessment) ________________________________________ (signature of physician, psychologist or capacity assessor who conducted the capacity assessment) Contact information of the physician, psychologist or capacity assessor who conducted the capacity assessment: Form 4 Capacity Assessment Report (Guardianship or Trusteeship or both) Adult Guardianship and Trusteeship Act (Sections 26, 46, 102) This form of capacity assessment report is to be used in respect of an application for a guardianship order or a trusteeship order (or both) under the Adult Guardianship and Trusteeship Act . “capacity” means, in respect of the making of a decision about a matter, the ability to understand the information that is relevant to the decision and to appreciate the reasonably foreseeable consequences of (a) a decision, and (b) a failure to make a decision. 1. I, (name of physician or psychologist) , am a registered member of the (name of the physician’s or psychologist’s professional college) . OR If the capacity assessor is not a physician or registered psychologist, the capacity assessor must complete the following: I, (name of capacity assessor) , am currently designated as a capacity assessor under the Adult Guardianship and Trusteeship Act . My designation is dated (day/month/year) . I was designated as a capacity assessor under the following Ministerial Order: (Ministerial Order number) . 2. This capacity assessment report is about (name of the adult) (the “adult”) of (address of the adult) , whose date of birth is (date of birth of the adult) . 3. The reason(s) or circumstances leading up to the request for this capacity assessment are 4. I have obtained confirmation that a medical evaluation of the adult was conducted by (name of physician or nurse practitioner) on (day/month/year) (within the 3‑month period immediately preceding the capacity assessment) and that the results of the medical evaluation did not indicate that the adult was suffering from a reversible temporary medical condition that appeared likely to have a significant impact on the adult’s capacity to make a decision about a personal matter or a financial matter. Comments: 5. The adult has been diagnosed by a physician as having the following medical condition(s) that is (are) relevant to this capacity assessment: Diagnosis: __________________________________________________ Name of physician: ___________________________________________ Date of diagnosis: (day/month/year) Comments: _____________________________________________ 6. Prior to conducting a capacity assessment of (name of the adult) I met with the adult and, unless the level of consciousness of the adult was such that the adult was non ‑ responsive, I explained to the adult (a) the purpose and nature of the capacity assessment, (b) that the adult has the right to refuse (i) to undergo the capacity assessment, or (ii) to continue with the capacity assessment at any point during the capacity assessment, (c) that the adult has the right to (i) have a person present to assist the adult in feeling comfortable and relaxed when undergoing the capacity assessment, and (ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate the adult’s capacity during the capacity assessment, (d) the significance and effect of a finding that the adult does not have the capacity to make decisions respecting a personal matter or a financial matter, and (e) that if a person who is present to assist the adult during the capacity assessment is, in my opinion, interfering with the capacity assessment, the person may be asked to leave. Comments:__________________________________________________ 7. The level of consciousness of the adult at the time of the capacity assessment was □ (a) alert, □ (b) fluctuating, or □ (c) non‑responsive. Comments:__________________________________________________ Note: Provide any comments you may have. If the adult’s level of consciousness was such that the adult was non‑responsive you must indicate that here. 8. The adult □ (a) appears to be capable of understanding the purpose of the capacity assessment, or □ (b) does not appear to be capable of understanding the purpose of the capacity assessment. 9. The adult has □ (a) refused to undergo or to continue with the capacity assessment, or □ (b) not refused to undergo or to continue with the capacity assessment. If (a) has been checked above, □ (a) a capacity assessment was not conducted, or □ (b) the capacity assessment was discontinued. Comments:__________________________________________________ 10. The adult chose to □ have the following person present to assist the adult in feeling comfortable and relaxed during the capacity assessment: (name of person present and relationship to the adult) □ use the following assistive device or had the following person present to assist with communication during the capacity assessment: (device used or name of person present and role, e.g. language interpreter) 11. Ba sed on the information that was provided to me, I have determined that an assessment of the capacity of the adult to make decisions is warranted with respect to the following: □ (a) personal matters Comments:__________________________________________________ □ (b) financial matters Comments:__________________________________________________ 12. Unless the level of consciousness of the adult was such that the adult was non‑responsive, I asked the adult if there have been any significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s) identified in item 11 and the adult informed me that □ (a) there have been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s), or □ (b) there have not been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s). Comments:__________________________________________________ 13. I assessed the capacity of the adult to make decisions about the following personal or financial matters (or both) and my opinion respecting the adult’s capacity to make decisions about those matters is indicated in the first or second column below: Personal Matters Adult has capacity Adult does not have capacity Matter □ □ the adult’s health care □ □ where, with whom and under what conditions the adult is to live, either permanently or temporarily □ □ with whom the adult may associate □ □ the adult’s participation in social activities □ □ the adult’s participation in any educational, vocational or other training □ □ the adult’s employment □ □ the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult □ □ other (specify) Note: Draw a line through any matters in respect of which you have not assessed the adult’s capacity. The reasons for my opinion are as follows: (set out the reasons) _______________________ Financial Matters Adult has capacity Adult does not have capacity Matter □ □ financial matters Note: Draw a line through this section if you have not assessed the adult’s capacity to make decisions about financial matters. The reasons for my opinion are as follows: (set out the reasons) In forming my opinion about the adult’s capacity to make decisions about the specified personal or financial matter(s), (a) I considered the adult’s ability to understand the information that is relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision and a failure to make a decision about the matter(s), and (b) I took into account (i) whether the adult has the ability to retain information that is relevant to decisions about the matter(s), and (ii) the following additional factors, if any: (specify) _____________________________________________. Comments: 14 . If in item 13 I have stated that in my opinion the adult does not have the capacity to make decisions about one or more matter(s), I have given consideration to whether the adult is likely to regain some or all of their capacity to make decisions about the matter(s) and I believe that the adult □ (a) is likely to regain some or all of the capacity to make decisions about the matter(s) and I recommend that another capacity assessment of the adult be conducted by no later than (day/month/year) , or Comments: □ (b) is not likely to regain some or all of the capacity to make decisions about the matter(s). Comments: 15. I have attached more detailed information respecting the capacity assessment. □ Yes. I have attached the following documents: ___________ ______________________________________________ □ No. 16 . In my opinion, serving the adult with notice of an application for a guardianship or trusteeship order □ (a) is not likely to cause serious emotional or physical harm to the adult, or □ (b) is likely to cause serious emotional or physical harm to the adult for the following reasons: (set out the reasons) Dated at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________ (print name of physician, psychologist or capacity assessor who conducted the capacity assessment) ________________________________________ (signature of physician, psychologist or capacity assessor who conducted the capacity assessment) Contact information of the physician, psychologist or capacity assessor who conducted the capacity assessment: Form 5 Complaint Respecting a Co‑decision‑maker, Guardian or Trustee Adult Guardianship and Trusteeship Act (Section 75) 1 Your contact information (a) What is your name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)? (b) What is your relationship to the assisted adult or represented adult? 2 Information about the assisted adult or represented adult (if known) What is the assisted adult’s or represented adult’s name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)? 3 Information about the co-decision-maker, guardian or trustee who is the subject of your complaint (if known) What is the co‑decision-maker’s or guardian’s or trustee’s name, address, preferred telephone contact number and alternate telephone number (if any), e‑mail address (if any), and fax number (if any)? 4 Information about the co‑decision-making, guardianship or trusteeship order (if known) Provide any other relevant information you have about the co‑decision-making, guardianship or trusteeship order. (For example, the matters with respect to which the co‑decision maker, guardian or trustee has authority.) 5 Nature of your complaint (a) What are your reasons for believing the co‑decision‑maker, guardian or trustee is failing to comply with the co‑decision‑making, guardianship or trusteeship order or the duties of a co‑decision‑maker, guardian or trustee? Include the date or time period when your concerns arose. (b) What are your reasons for believing that the failure is (i) likely to cause harm to the physical or mental health of the assisted adult or represented adult? (ii) likely to cause financial loss to the represented adult? (c) Have you taken any steps to resolve the matter? Set out the details in the space below. 6 People who can provide further information Provide the full name, title (if any), address and preferred telephone contact number and alternate telephone number (if any), of any person who may be able to provide further information about this complaint or about the assisted adult’s or represented adult’s circumstances and set out the person’s relationship to the assisted adult or represented adult. (NOTE: If the subject‑matter of your complaint could be an offence under the Criminal Code (Canada), abuse against a client under the Protection for Persons in Care Act or an offence under another statute or regulation of Alberta, the complaints officer may refer the complaint to a police service or appropriate government ministry in accordance with s79(1) of the Adult Guardianship and Trusteeship Act .) Dated at (location) in the Province of Alberta this (day) of (month) , (year) . Signature of person making complaint The personal information you have provided is being collected under section 78 of the Adult Guardianship and Trusteeship Act and may be used for the purposes of conducting an investigation or resolving a complaint under sections 75 to 79 of the Adult Guardianship and Trusteeship Act , making an application under section 26, 46 or 74 of the Adult Guardianship and Trusteeship Act or as authorized or required under the Protection of Privacy Act or another enactment. If you have any questions about this collection, you may contact the complaints officer at the Office of the Public Guardian. Form 6 Specific Decision Making Adult Guardianship and Trusteeship Act (Sections 87, 90, 91, 100.2) Part 1 - Assessment of Capacity This part is to be completed by the health care provider that is assessing the capacity of the adult. 1. I, (name of physician, nurse practitioner or dentist) , met with (name of the adult) (the “adult”) on (day/month/year) to assess the adult’s capacity to do the following: □ (a) make a decision to consent or refuse to consent to the following proposed health care for the adult: (describe the proposed health care) ; □ (b) make a decision to consent or refuse to consent to the adult’s proposed □ (i) temporary admission to, or □ (ii) discharge from the following residential facility: (set out the name of proposed residential facility, including a transitional facility) ; □ (c) make decisions about financial matters. 2. Prior to conducting a capacity assessment of (name of the adult) I met with the adult and, unless the level of consciousness of the adult was such that the adult was non ‑ responsive, I explained to the adult (a) the purpose and nature of the capacity assessment, (b) that the adult has the right to refuse (i) t o undergo the capacity assessment, or (ii) to continue with the capacity assessment at any point during the capacity assessment, (c) that the adult has the right to (i) h ave a person present to assist the adult in feeling comfortable and relaxed when undergoing the capacity assessment, and (ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate the adult’s capacity during the capacity assessment, (d) the significance and effect of a finding that the adult does not have the capacity to make decisions about a personal matter or financial matter, and (e) that if a person who is present to assist the adult during the capacity assessment is, in my opinion, interfering with the capacity assessment, the person may be asked to leave. Comments: 3. The level of consciousness of the adult at the time of the capacity assessment was □ (a) alert, □ (b) fluctuating, or □ (c) non ‑ responsive. Comments: Note: Provide any comments you may have. If the adult’s level of consciousness was such that the adult was non‑responsive you must indicate that here. 4. The adult □ (a) appears to be capable of understanding the purpose of the assessment, or □ (b) does not appear to be capable of understanding the purpose of the assessment. 5. The adult has □ (a) refused to undergo or to continue with the assessment, or □ (b) not refused to undergo or to continue with the assessment. If (a) has been checked above, □ (a) an assessment was not conducted, or □ (b) the assessment was discontinued. Comments: 6. The adult chose to □ have the following person present to assist the adult in feeling comfortable and relaxed during the capacity assessment: (name of person present and relationship to the adult) □ use the following assistive device or had the following person present to assist with communication during the capacity assessment: (device used or name of person present and role, e.g. language interpreter) 7. I assessed the capacity of the adult, and my opinion is the following: □ (a) the adult has the capacity to make the decision(s) described in item 1 (insert subsection(s)) above, because the adult (i) understands the information that is relevant to the decision(s), and (ii) appreciates the reasonably foreseeable consequences of the decision(s) and of failing to make the decision(s); □ (b) the adult does not have the capacity to make the decision(s) described in item 1 (insert subsection(s)) above, because the adult (i) does not understand the information that is relevant to the decision(s), and (ii) does not appreciate the reasonably foreseeable consequences of the decision(s) and of failing to make the decision(s). 8. ( Complete this item only if item 7(b) is selected ) I informed the adult that I assessed them as not having the capacity to make a decision described in item 1 (insert subsection(s)) above, and I informed the adult that they have the following right(s): □ (a) the right to (i) apply to the Court, under section 97 of the Adult Guardianship and Trusteeship Act , for a review of this assessment of the adult’s capacity and for a review of a decision of a specific decision maker, and (ii) request a capacity assessment under section 96 of the Adult Guardianship and Trusteeship Act ; □ (b) the right to apply to the Court, under section 100.5 of the Adult Guardianship and Trusteeship Act , for a review of this assessment of the adult’s capacity and for a review of a financial decision of the Public Trustee. □ ( check if applicable ) I am unable to certify that the adult comprehended the information referred to in this item Part 2 — Declaration of Specific Decision Maker This part is to be completed by the specific decision maker. 1. I, (name of specific decision maker) have been selected by (name of physician, nurse practitioner or dentist who selected the specific decision maker) to make a decision for (name of the adult) (the “adult”) to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 of Part 1 of this form. 2. I declare that I am the nearest relative of the adult who (a) is 18 years of age or older, (b) is available and willing to make the decision, (c) is able to make the decision, (d) has been in contact with the adult in the previous 12 months, (e) has knowledge of the adult’s wishes respecting the decision to be made or of the beliefs and values of the adult, and (f) does not have a dispute with the adult that might affect my ability to comply with the duties of a specific decision maker. I further declare that (a) I will carry out the duties and responsibilities of a specific decision maker, and (b) I will comply with the requirements of Part 3, Division 1 of the Act in making a decision for the adult. 3. I understand that I am required to make reasonable efforts to notify the nearest relative of the adult, other than me, of the decision made and to notify the Public Guardian of the decision made if I am not able to notify the nearest relative. Dated at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________ (print name of specific decision maker) ________________________________________ (signature of specific decision maker) Contact information of specific decision maker:__________________________________________________________________________________________________________________ ____________________________________________________________ (print name of witness) ________________________________________ (signature of witness) Part 3 — Record of Health Care Provider This part is to be completed by the health care provider who selected the specific decision maker. 1. □ I selected the following person to make a decision for (name of the adult) to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 of Part 1 of this form: □ _________________________________, or (name of specific decision maker) □ the Public Guardian. □ The Public Guardian authorized (name of person authorized by Public Guardian) to make a decision for (name of the adult) to consent or refuse to consent to the proposed health care, admission or discharge described in item 1 of Part 1 of this form. 2. The specific decision maker made the following specific decision for the adult on (day/month/year) : □ (a) that the adult receive the health care described in item 1 of Part 1 of this form, specifically, (describe the proposed health care) OR □ (b) that the adult be □ (i) temporarily admitted to, or □ (ii) discharged from the residential facility set out in item 1 of Part 1 of this form, specifically, (set out the name of proposed residential facility, including a transitional facility) Dated at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________ (print name of physician, nurse practitioner or dentist who selected the specific decision maker) ________________________________________ (signature of physician, nurse practitioner or dentist who selected the specific decision maker) Contact information of the physician, nurse practitioner or dentist who selected the specific decision maker: Forms 7 to 9 Repealed AR 47/2010 s3. Form 10 Capacity Assessment Report (Specific Decision Making) Adult Guardianship and Trusteeship Act (Sections 96, 100.5, 102) This form of capacity assessment report is to be used in respect of a capacity assessment under section 96 or 100.5 (or both) of the Adult Guardianship and Trusteeship Act relating to the capacity of an adult to make decisions about one or more of the following: (a) health care; (b) temporary admission to or discharge from a residential facility; (c) financial matters. “capacity” means, in respect of the making of a decision about a matter, the ability to understand the information that is relevant to the decision and to appreciate the reasonably foreseeable consequences of (a) a decision, and (b) a failure to make a decision. 1. I, (name of physician or psychologist) , am a registered member of the (name of the physician’s or psychologist’s professional college) . OR If the capacity assessor is not a physician or registered psychologist, the capacity assessor must complete the following: I, (name of capacity assessor) , am currently designated as a capacity assessor under the Adult Guardianship and Trusteeship Act . My designation is dated (day/month/year) . I was designated as a capacity assessor under the following Ministerial Order: (Ministerial Order number) . 2. This capacity assessment report is about (name of the adult) (the “adult”) of (address of the adult) , whose date of birth is (date of birth of the adult) . 3. The reason(s) or circumstances leading up to the request for this capacity assessment are______________________________________ ___________________________________________________________ 4. Prior to conducting a capacity assessment of (name of the adult) I met with the adult and, unless the level of consciousness of the adult was such that the adult was non ‑ responsive, I explained to the adult (a) the purpose and nature of the capacity assessment, (b) that the adult has the right to refuse (i) to undergo the capacity assessment, or (ii) to continue with the capacity assessment at any point during the capacity assessment, (c) that the adult has the right to (i) have a person present to assist the adult in feeling comfortable and relaxed when undergoing the capacity assessment, and (ii) the assistance of a person or the use of a device to communicate in order for the adult to be able to fully demonstrate the adult’s capacity during the capacity assessment, (d) the significance and effect of a finding that the adult does not have the capacity to make decisions respecting a personal matter or a financial matter, and (e) that if a person who is present to assist the adult during the capacity assessment is, in my opinion, interfering with the capacity assessment, the person may be asked to leave. Comments:__________________________________________________ 5. The level of consciousness of the adult at the time of the capacity assessment was □ (a) alert, □ (b) fluctuating, or □ (c) non‑responsive. Comments:__________________________________________________ Note: Provide any comments you may have. If the adult’s level of consciousness was such that the adult was non ‑ responsive you must indicate that here. 6. The adult □ (a) appears to be capable of understanding the purpose of the capacity assessment, or □ (b) does not appear to be capable of understanding the purpose of the capacity assessment. 7. The adult has □ (a) refused to undergo or to continue with the capacity assessment, or □ (b) not refused to undergo or to continue with the capacity assessment. If (a) has been checked above, □ (a) a capacity assessment was not conducted, or □ (b) the capacity assessment was discontinued. Comments: _____________________________________________ 8. The adult chose to □ have the following person present to assist the adult in feeling comfortable and relaxed during the capacity assessment: (name of person present and relationship to the adult) □ use the following assistive device or had the following person present to assist with communication during the capacity assessment: (device used or name of person present and role, e.g. language interpreter) 9. Based on the information that was provided to me, I have determined that an assessment of the capacity of the adult to make decisions is warranted with respect to the following: □ (a) health care Comments:__________________________________________________ □ (b) in respect of a residential facility, □ (i) temporary admission to a residential facility, or □ (ii) discharge from a residential facility Comments:_______________________________________________ □ (c) financial matters. Comments:_______________________________________________ 10.

Unless the level of consciousness of the adult was such that the adult was non‑responsive, I asked the adult if there have been any significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s) identified in item 9 and the adult informed me that □ (a) there have been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s), or □ (b) there have not been significant changes recently in the adult’s beliefs and values related to making decisions about the matter(s). Comments:__________________________________________________ 11. I assessed the capacity of the adult to make decisions about the following personal or financial matters (or both) and my opinion respecting the adult’s capacity to make decisions about those matters is indicated in the first or second column below: Adult has capacity Adult does not have capacity Matter □ □ the adult’s health care □ □ temporary admission to a residential facility □ □ discharge from a residential facility □ □ financial matters Note: Draw a line through any matters in respect of which you have not assessed the adult’s capacity. The reasons for my opinion are as follows: (set out the reasons) ____________________________________________________________ In forming my opinion about the adult’s capacity to make decisions about the specified matter(s), (a) I considered the adult’s ability to understand the information that is relevant to a decision and to appreciate the reasonably foreseeable consequences of a decision and a failure to make a decision about the matter(s), and (b) I took into account (i) whether the adult has the ability to retain information that is relevant to decisions about the matter(s), and (ii) the following additional factors, if any: (specify) . Comments: 12. I have attached more detailed information respecting the capacity assessment. □ Yes. I have attached the following documents: ___________ ______________________________________________ □ No. Dated at (location) in the Province of Alberta this (day) day of (month) , (year) . ________________________________________ (print name of physician, psychologist or capacity assessor who conducted the capacity assessment) ________________________________________ (signature of physician, psychologist or capacity assessor who conducted the capacity assessment) Contact information of the physician, psychologist or capacity assessor who conducted the capacity assessment: Form 11 Notice of Financial Decision(s) Adult Guardianship and Trusteeship Act (Section 100.6) Under section 100.6(1) of the Adult Guardianship and Trusteeship Act , the Public Trustee provides notice of the following financial decision(s) made on behalf of (name of adult) : (Describe financial decision(s)) Under section 100.6(2) of the Adult Guardianship and Trusteeship Act, the person receiving this notice must carry out the Public Trustee’s financial decision(s). Section 100.8(2) of the Adult Guardianship and Trusteeship Act provides that no action lies against a person for anything done or omitted to be done in good faith while carrying out the Public Trustee’s financial decision(s) set out in this notice. Date Public Trustee for the Province of Alberta AR 224/2009 Sched.;47/2010;77/2012; 90/2020;142/2025;158/2025;43/2026