Congratulations, you have taken an important step forward in planning your future! This instruction sheet will help you to write a personal directive, using the voluntary standard form.

A personal directive is a legal document under the Personal Directives Act that allows you to name a person(s) you trust to make decisions on your behalf after you no longer have the capacity to make decisions. Your personal directive needs to be dated, written, signed by you and witnessed. The black titles in the form are required information and the green titles are optional to include more information, if you choose. Please initial beside your item(s) to confirm this is your choice.

Name

I, ________________________________________________________, make this Personal Directive.
(name of maker)

Print your name here. You are the maker of this personal directive and will be referred to as the maker for the rest of the form.

1. Revocation of Previous Directive

If you already have a personal directive in place, this section allows you to revoke or replace it with this new one. Please initial to indicate you agree with this revocation. If you have never written a personal directive before, proceed to section 2.

2. Designation of Agent

An agent is someone you name to make decisions for you when you no longer have the mental capacity to make these decisions. It is strongly recommended you choose someone you trust, and who will be able to carry out this important role; typically family or friends.

You have three options:

• you can name one or more agents. When naming several agents consider the following:
  • you can name a primary agent and one or several alternate agents. An alternate agent makes decisions when the agent named before is unable or unwilling to make a decision. Please indicate on the form if the agent is primary or alternate.
  • you can name joint agents, in this case each agent has the same authority and service providers must contact each agent to request a decision. If this is your preference please indicate the name of your agents and specify that they are named jointly.
• you can name the Office of the Public Guardian (OPG) if you have no family or friends able to take on this role. Before you name the OPG as your agent, contact the OPG at 1-877-427-4525 for more information or
• you can decide not to name an agent and your personal directive would only provide instructions and information.

3. Areas of Authority

You have the option of providing your agent(s) with decision-making authority after you no longer have the mental capacity for all personal matters (e.g. health care, accommodation, etc.). You can identify which personal matters are included and which agent(s) has authority over each matter. This will allow you to make it clear when different agents are named for different personal matters.

4. Designation of Agent for Temporary Care and Education of Minor Child(ren) (Optional)

You have the option to name an agent to make decisions for temporary care and education of your children. This agent may be different from the other agents you have chosen and will continue to make decisions for your children until the court appoints a legal guardian.

5. Specific Instructions (Optional)

You have the option to provide specific instructions to your agent. This may include instructions on health care matters such as medical treatments. Discuss with your health care provider so they can provide you with accurate information.

If you do not name an agent, you can provide instructions to service providers. Again it is important to discuss these instructions with health providers to ensure your instructions reflect your wishes. If you do not want to provide any written instruction, go to section 6.

6. Other Information (Optional)

You have the option to include information on your religious beliefs, cultural preferences or other items that provide more contextual guidance for your agent in future decision making. If you have no information to add, go to section 7.

7. Who Determines my Capacity (Optional)

You have the option of naming a person you trust to assess your capacity in order to bring your personal directive into effect. This person should know you well, such as a close family member or friend. The person you name here would assess your capacity according to the Personal Directives Act and Regulations to consult with a physician or psychologist.

You don't need to name someone to assess your capacity. If you don't, two service providers, one of whom will be a physician or psychologist, will assess your capacity. If you have no information to add, go to section 8.

8. Notification (Optional)

This allows you to name someone in addition to your agent who you would like to be notified when your personal directive is in effect. If you do not wish to do this, proceed to section 9.

9. Signature

Your signature is required. You must sign and date your personal directive in front of a witness. There are certain persons who cannot be a witness and they are listed on the form.

10. Acknowledge (Optional)

This option allows the person you name as agent to acknowledge their future role. The more your agent knows ahead of time, the better informed they will be to carry out your wishes.

Congratulations you have completed your personal directive!

Please be sure to keep your signed and witnessed original personal directive in a safe place that others can access when needed. It is strongly recommended to give a copy to your agent(s), physicians, and service providers. You may also want to register that you have a personal directive by phone or online at www.seniors.alberta.ca/opg/registry. For more information, contact our toll free line at 1-877-427-4525.