Assessment and Investigation Services Referral | Public Guardian and Trustee of British Columbia

Mandatory Fields

Overview

Information you provide in this form is to assess and investigate a report about the alleged abuse, neglect or self-neglect of an adult who may be vulnerable.

This form requires you to provide your name, phone number and relationship with the adult you are concerned about. Your identity is protected from disclosure by law. If you have any questions please contact our Assessments and Investigations department at 1-877-511-4111.

Information is collected under the Freedom of Information and Protection of Privacy Act (FOIPPA) and other applicable legislation. If you have any questions about the collection, use or disclosure of information, contact the PGT’s Information and Privacy Officer at 604-660-4444 or mail@trustee.bc.ca.

The adult’s personal information

Reason for the referral

Understanding the adult's situation helps us conduct an effective, timely investigation. Please provide us with the following information regarding risk to income and assets or potential legal matters.

Do any of the adult’s assets require urgent protection?

Yes

Unsure

Assets may need urgent protection when there is evidence that they have been or are at risk of being stolen or used fraudulently.

Provide details

Is the adult aware of this referral?

Yes

Unsure

What was their response?

Why is the adult not aware of this referral?

Describe the problems the adult needs help resolving, including details about the urgent and immediate need for support.

What is the concern you have about the adult’s mental capacity to manage financial and legal matters?

How are the adult's affairs being managed and if relevant, please provide the name of organization or person supporting the adult

Is there a person willing and able to act on the adult’s behalf?

The adult’s medical information

Please provide details about the medical assistance the adult is receiving and any related service provider's contact information that you have.

The adult is assisted by the following:

Health authority

Contact first name

Contact last name

Phone

Role

For example, physician, social worker, nurse.

Program and location

Provide details and contact information for any programs the adult may be involved in. (for example: home health, mental health, acquired brain injury)

Program 1

Program name

Contact first name

Contact last name

Phone

Is the adult assisted by Community Living BC?

Yes

Unknown

Contact first name

Contact last name

Phone number

Is this person being served by any physicians?

Yes

Unknown

Physician 1

Physician first name

Physician last name

Street address

Apartment/Suite #

City

Province/State

Postal code/ZIP code

Country

Phone

Fax

People in the adult’s life

Please provide details about people/organizations in the adult's life who you have not already included.

You may enter up to 10 persons.

Person 1

First name

Last name

Phone

Street address

Apartment/Suite #

City

Province/State

Postal code/ZIP code

Country

Relationship to adult

Describe other

Specify relation

Is this person Power of Attorney or Representative?

Yes

Unknown

Is this person aware of this referral?

Yes

Unknown

Describe why this person is not aware of the referral

The adult’s financial information

Supporting documents

Please attach any supporting documents related to the adult that you think will support this referral.

Attach any additional documents to support this referral

Document file types can be any and only these formats: .pdf, .doc, .docx, .xls, .xlsx, .rtf, .txt, .jpg, .jpeg, .tiff, .tif, .csv, or .png.

Each file must be under 25 MB, and the form has a 150 MB limit for all attachments.

Please do not password-protect files, as this will prevent the PGT's system from scanning for viruses. Files that cannot be checked for viruses will be securely deleted.

Referring party

Please provide your contact details so we can discuss your concerns in more detail. Your identity is protected from disclosure by law. If you have any questions, please get in touch with our Assessment and Investigations department at 1-877-511-4111.

First name

Last name

Relationship to the adult

Street address

Apartment/Suite #

City

Province/State

Postal code/ZIP code

Country

Phone

Alternate phone

Report concerns about an adult's financial and legal affairs

Sections in this form