Mandatory Fields
Overview

This form is for admissions managers to seek consent from the Public Guardian and Trustee (PGT), as substitute decision maker, for an adult to be admitted to a care facility admission or remain in a facility.

Under Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, informed consent must be obtained before an adult is admitted to a residential care facility. In cases where the adult has been assessed as incapable of providing informed consent, a substitute decision maker is required. For more information, please see Practice Guidelines for Seeking Consent to Care Facility Admission and B.C. Government Consent to Care Facility Admission.

The adult must be aged 19 or over and determined to be incapable of making the decision by either an Incapability Assessment Report for Care Facility Admission Decisions, which must be submitted to the PGT, OR a court order that appoints the PGT as the adult’s Committee of Person.

Information you provide is for the purpose of making a decision about admission to, or continued residence in, a care facility for an adult who is not able to consent themselves. 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.

Reason for the referral
Please provide as much information as you can to assist the PGT in making a timely decision that meets the adult’s best interests.
Select the scenario that applies to this referral
Decision type
Select the scenario that applies to this referral
Does the Public Guardian and Trustee have Committee of Person?
Committee of Person is a court ordered authority that gives someone the authority over an adult’s health and personal care.
You must attach an Incapability Assessment Report as the PGT requires this in order to proceed

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.

Has explaining the results of their incapability assessment been waived due to the risk/harm that may result in the adult knowing?
Does the adult understand they need a substitute decision maker and have the right to a second assessment made by a different assessor?
Attach any additional documents as supporting materials when sending us this referral (psychological assessment, residential assessment instrument)

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.

The PGT as substitute decision maker, is required by the Health Care (consent) and Care Facility (Admission) Act to make a decision in the adult's best interests. Please provide as much information as you can to support the PGT in being a substitute decision maker (adult’s best interests means that a substitute decision maker must take into consideration the adult’s current wishes, and any wishes the adult expressed previously, as well as their values and beliefs. The substitute must also consider whether going into a care facility will be beneficial for the adult and whether there are other less restrictive options available to meet their needs).
The adult's personal information
Please share any name(s) this person may use that is not their legal name.
Date of birth
Personal health number
The Personal health number is a 10-digit number. Do not include dashes, spaces, or letters.
Is the adult Indigenous
The PGT can arrange for an interpreter to support this referral if the adult’s primary language is not English.
Current location of the adult
People in the adult's life
Please provide details about people in the adult's life. Include their involvement in the substitute decision making process. Information on each person helps us assess this referral.
You may enter up to 4 persons.
Person 1
Has this person been contacted?
Does this person want to assist the adult with this decision?
Has this person been disqualified as a substitute decision maker?
If disqualified, have they been informed of disqualification and right to seek legal counsel?
Facility considerations
Please provide any information about a care facility that is best suited for the adult.
Provide a maximum of three specific facilities that best meet the adult's needs that you may know of. This guidance is helpful.
Facility
Facility 1
Referring party
Please provide your contact details so we can contact you about this referral. We will confirm to whom we should address the consent letter.

Sections in this form

Download a copy of your referral for your records before you submit. You will not be able to save a copy of the form after you submit it.