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Client intake

Representation agreement intake

This is the intake we draft a representation agreement from: who you are appointing to make health and personal care decisions for you if you cannot, and what you want them to be able to decide. Your answers are kept on this device until you send them, so you can stop and come back.

5 sections. Your answers are kept on this device until you send them or clear them. Nothing leaves it until you press send.

Not this one? Back to the start

  1. 1 About you
  2. 2 Your representative
  3. 3 What your representative can decide
  4. 4 How it should work
  5. 5 Reaching you

About you

Full legal names, exactly as they appear on government identification. No initials.

Relationship status

Only if it applies to you.

Does your spouse want a representation agreement as well?

Only if it applies to you.

Your representative

The person who will speak for you. They have to be an adult, and they cannot be someone paid to provide you with care unless they are also family. Choose someone who knows what you would want and is willing to say so to a doctor.

Full legal names, exactly as they appear on government identification. No initials.

Spouse, daughter, brother, friend, and so on.

Do you want an alternate, if your representative cannot act?

Only if it applies to you.

Full legal names, exactly as they appear on government identification. No initials.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Only if it applies to you.

Spouse, daughter, brother, friend, and so on.

Only if it applies to you.

How should they act?
Do you want a monitor?

A monitor is a person named in the agreement whose job is to check that the representative is doing what the agreement says. Often unnecessary where the representative is a spouse or child; worth considering otherwise.

What your representative can decide

Each of these is a separate grant of authority. Turn on the ones you want. Where you are not sure, say so and we will explain what each involves at the meeting.

Routine health care: a prescription, a test, a minor procedure
Major health care: surgery, a general anaesthetic, chemotherapy, dialysis and the like
Where you live, and with whom
Admission to a care facility
Consenting to care you have refused before, if the representative believes it is what you would now want
Refusing, or agreeing to stop, treatment that is keeping you alive

The most serious grant in the document, and the one most people make it for.

Arranging temporary care for your minor children, or for anyone else who depends on you
If you are dying, do you want comfort and pain relief even where it may shorten your life?

For example: no blood transfusions, a preference to die at home, a faith requirement, a treatment you would never want. These can go in the agreement, or in a separate advance directive that health providers act on directly.

Some decisions cannot be handed to anyone else. Under current British Columbia law a representative cannot request medical assistance in dying on your behalf. If that matters to your planning, raise it at the meeting.

How it should work

When should the agreement take effect?
Have you made a representation agreement before?

Only if it applies to you.

Should the new agreement cancel the old one?
Do you have an enduring power of attorney?

A representation agreement covers your care. Your property and finances need a power of attorney, which has its own short intake.

Only if it applies to you.

Do you want us to prepare one at the same time?
Should your representative be paid?

Reaching you

How you would rather be contacted, who to thank for sending you, and anything the questions above did not cover.

How would you rather be contacted?
How did you hear about the firm?

Only if it applies to you.

Optional, and the only reason we ask is so we can.

Anything the questions above did not cover: a diagnosis that affects how the agreement will be used, a family member who should or should not be involved, anything you would want your representative to know.

Before you send it

1 of 5