HEALTH CARE PROFESSIONAL REPORT

Protective Division – Guardianship Stream

Purpose of Report

An application made under the Guardianship and Administration Act 1995 in respect of a person is to be supported by a report by a health care professional. Examples of suitable health care professionals are medical practitioners, psychologists, neuro-psychologists and psychiatrists.

A person you have assessed and/or provided treatment to in a professional capacity is or is intended to be the subject of an application before the Tasmanian Civil and Administrative Tribunal (the Tribunal).

The Tribunal is an independent statutory authority that can appoint a guardian and/or administrator; provide consent to medical treatment; review an enduring power of attorney and/or enduring guardian instrument and pursuant to the Disabilities Services Act 2011, can approve the use of restrictive practices.

A person is presumed to be capable of making their own decisions unless the Tribunal determines on the evidence before it that the person is not capable to do so. The Tribunal requires comprehensive evidence from a medical practitioner or psychologist about whether the person has a disability and the effect of the disability on the person’s mental capacity and their ability to make specific decisions.

disability means any restriction or lack (resulting from any absence, loss or abnormality of mental, psychological, physiological or anatomical structure or function) of ability to perform an activity in a normal manner - s.3 Guardianship and Administration Act 1995

On the application proceeding to hearing this Report will form part of the evidence in the hearing to determine the application.

Payment for the Report

Any fee for this report will be paid from the estate of the person to whom it relates. Please forward the account to the person who requested the report.

Confidentiality

The information you provide about the person needs to be comprehensive and detailed as it is part of the information relied upon by the Tribunal to determine an Application. It will be necessary for the Tribunal to disclose the report to the person and other parties to the proceedings.

Section 86 of the Guardianship and Administration Act 1995 prohibits a person from disclosing information obtained by the Tribunal under the Act that deals with the personal history or records of a person, except at hearing or with appropriate authority as set out in the section.

For information on completing this Health Care Professional Report Form please contact the Tribunal on 1800 657 500.

Thank you for your time in completing this Report.

Please Note: Once completed, please return this Report to the applicant. You may be asked to attend a hearing and provide further evidence at the hearing to the Tribunal. The Tribunal can summons any witness to a Tribunal hearing for the purpose of giving evidence or producing a document.

HEALTH CARE PROFESSIONAL REPORT

Health Care Professional Report Page 1 of 9

Health Care Professional Report Protective Division – Guardianship Stream

1. Details about the person the Application is about Title � Dr � Mr � Mrs � Ms � Miss Other specify__________

Given name(s)

Family name

Date of Birth

2. Details of medical practitioner or psychologist Title � Dr � Mr � Mrs � Ms � Miss Other specify__________

Name

Organisation or practice

Address

Telephone

Email

In what capacity do you know the person? � Medical Practitioner � Psychologist

Please specify any relevant specialisations?

How long have you known the person?

How often do you see the person?

When did you last see the person?

3. Details of Applicant

Please give details of the person who is making the application and/or requested you to complete this form:

Name

Telephone / Email


4. Medical information about the person

In your opinion does the person have a disability? � Yes � No

If yes, please indicate (one or more):

� Dementia

State specific diagnosis if known (e.g. Vascular Dementia):

How long has the disability been evident?

This disability is � Mild � Moderate � Severe

This disability is � Stable � Slow progression � Rapid progression

� Intellectual Disability

State specific diagnosis if known (e.g. Down Syndrome):



This disability is � Static � Fluctuating � Improving � Deteriorating

� Acquired Brain Injury

State specific diagnosis if known (e.g. traumatic brain injury resulting from MVA):




� Mental Illness

State specific diagnosis if known (e.g. Schizophrenia):





� Other disability/conditions that affects the person’s decision making capacity (please specify)

State specific diagnosis if known:



This disability is � Static � Fluctuating � Improving � Deteriorating Does the person experience deficits in particular areas by reason of the stated disabilities? � Orientation to person, place or time � Planning and Reasoning skills

� Expressive communication � Impulse control

� Receptive communication � Susceptibility to influence/suggestibility In your opinion does the person’s disability affect their capacity to make reasonable judgements about the following matters:

Financial and Legal

Day to day financial requirements? (i.e. operate a bank account, pay accounts, budget) � Yes � No If yes, provide details of how you formed this view

Complex financial and legal decisions? (e.g. purchase or sale of a major asset, management of large sums of money, negotiating a disputed debt, pursuing entitlements including income and superannuation) � Yes � No If yes, provide details of how you formed this view

Legal matters (e.g. ability to commence, defend or settle legal proceedings; entering into a contract i.e. Aged Care Financial Agreement) � Yes � No If yes, provide details of how you formed this view


In your opinion does the person’s disability affect their capacity to make reasonable judgements about the following matters:

Personal Decision Making

Where to live (permanently or temporarily)? � Yes � No If yes, provide details of how you formed this view

Medical treatment and Healthcare? � Yes � No If yes, provide details of how you formed this view

Support services they should access and need? � Yes � No If yes, provide details of how you formed this view

NDIS (involvement in planning, reviews, selection of services and supports)? � Yes � No If yes, provide details of how you formed this view

Restrictive Practices [including under the Disability Services Act 2011] – (For the purpose of behaviour control or restricting the liberty of movement of the person) � Yes � No If yes, provide details of how you formed this view

Other personal or lifestyle matters (e.g. visits by friends or relatives; employment or travel. � Yes � No If yes, specify the personal or lifestyle matter and provide details of how you formed this view


5. Assessments What tests or examinations have been conducted to support diagnosis and your opinion about decision making ability (e.g. MMSE, MoCA, neurological or psychological assessments, brain scans)? Please attach copies of any relevant assessments/reports, but if not available the nature, dates and results of any assessments and author of any reports.

6. Other Jurisdiction Orders Is the person subject to any other? (e.g. TASCAT Mental Health Stream; Supreme/Magistrates Court)

� Yes � No � Unsure If yes, provide details


7. Review of Enduring Power of Attorney applications

Only complete this section if the application is for a review of an Enduring Power of Attorney

When did the person (donor) sign an enduring power of attorney?

Did you know the person on this date?

� Yes � No

If yes, did you assess the person’s capacity to understand the creation and effect of the Enduring Power of Attorney? Detail the date and assessments/examinations conducted.

If no, are you able to express an opinion regarding the person’s probable capacity to create and sign an enduring power of attorney on this date? � Yes (please comment below) � No

Do you consider the person understood at the time of signing: (refer to section 30(2) and (3) Powers of Attorney Act (Tas)

• They could specify or limit the power to be given to the attorney and instruct their attorney about the exercise of the Power. � Yes � No

• When the Power begins. � Yes � No • That once the Power begins, and subject to any terms contained in the Power, the attorney will

have full control over their estate. � Yes � No • That the Power continues after they lose capacity. � Yes � No • They could vary or revoke the Power at any time provided they have capacity to do so.

� Yes � No

• They are unable to oversee the use of the Power if they subsequently lose capacity. � Yes � No

Any other relevant comment as to the person’s capacity and understanding of the power, at the time of execution?

Please ensure you complete Part 4 of this Form.


8. Review of Enduring Guardianship

Only complete this section if the application is for a review of an Enduring Guardianship Instrument

When did the person sign an enduring guardianship instrument?

Did you know the person on this date?

� Yes � No

If yes, did you assess the person’s capacity to understand the effect of the Enduring Guardian Instrument? � Yes � No Detail the date and assessments/examinations conducted

If no, are you able to express an opinion regarding the person’s probable capacity to create and sign an enduring guardianship instrument on this date?

Do you consider the person understood at the time of signing: (refer to section 32, Guardianship and Administration Act 1995)

• That the enduring guardianship could be a full guardianship or limited to specific decisions (e.g. health care or end of life care). � Yes � No

• That the guardian’s powers would not commence until they lose capacity to make reasonable judgements. � Yes � No

• That once the guardian’s powers commence, and subject to any terms contained in the Instrument, the guardian can make decisions relating to them or their personal circumstances. (e.g. decide whether they will live - residential aged care vs remaining at home) � Yes � No

• They could vary or revoke the Instrument at any time provided they have capacity to do so. � Yes � No

Any other relevant comment as to the person’s capacity and understanding of the power, at the time of execution?

Please ensure you complete Part 4 of this Form.


9. Other relevant information

Do you have other information or observation that may be relevant?

10. Person’s participation at the hearingPlease indicate if the person

� speaks English

� speaks another language and requires an Interpreter (please specify language) ………..……………..

� uses sign language / Makaton / language board (please specify)

� uses gestures or other body language to communicate

� is unable to communicate

The person has the right to attend and participate in the hearing. The Tribunal needs to ascertain the wishes of the person, as far as is possible at hearing. The person’s cognitive impairment or the practical difficulties in bringing them to the hearing are not generally sufficient reasons to prevent their participation.

Please indicate whether attending would be detrimental to the person’s health or wellbeing and the reasons for your opinion.

Have you discussed this report with the person?

� Yes - if yes, please specify the person’s views � No – if no, please specify the reasons why

Has the person expressed to you any views that may be relevant to this application? Provide details


11. Declaration

I declare that the information provided is true to the best of my knowledge and belief and the opinions expressed are within my knowledge and/or based upon information provided to me by other treating health care professionals.

Signature of person completing this report

Date

Please return this Report directly to the applicant.

HEALTH CARE PROFESSIONAL REPORT

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