For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity – Guardianship and Administration Act 2000
BEFORE YOU GO ANY FURTHER... check that you really need to make this application.
The purpose of this form is to ask QCAT to declare that a particular person has the capacity to make decisions in relation to a matter.
The person whose capacity you are seeking to establish could be a guardian, administrator, or the adult him/herself.
• Whocanmakethisapplication?
You can make this application if you are:
• the adult concerned, or
• a guardian, administrator or attorney, or
• anyone else with an interest.
• HowdoIcompletethisform?
You work through the form, answering each question as it comes by ticking the appropriate box or writing on the lines provided. Some of the questions have space for names, addresses, short explanations and other details.
Do not skip any questions unless the instructions tell you to.
The form itself is divided into six parts:
• preliminarydetails(whichhassectionson‘Basicinformationabouttheperson’, ‘Informationabouttheperson’sallegedimpairedcapacity’and‘Priority’)
• informationabouttheguardian/s,administrator/s,andattorney/s
• informationabouttheapplication
• informationaboutanyoneelseconcerned
• person’srequirementsattheQCAThearing
• basicinformationaboutyou,theapplicant.
• WhatelsedoIhavetodotomakethisapplication?
You have several responsibilities. They are:
• toinformtheadultconcernedthatyouhavemadeanapplication,andexplainwhy(unless,ofcourse,youaremakingtheapplicationonyourownbehalf)
• tosupplyatleastonewrittenreportfromahealthprovideroutliningthenatureoftheperson’sallegedimpairedcapacityorabilitytomanagehis/herpersonaland/orfinancialaffairs;or,ifforsomereasonyoucannotsupplyityourself,toexplainwhyyouhaven’tattachedittotheform,and how the tribunal can obtain a copy
• togiveQCATthenamesandcontactdetailsofeveryonewhohasaninterestinyourapplication, even if they disagree with it
Instructionsforcompleting
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
• WhatelsedoIhavetodotomakethisapplication?
• toattendtheQCAThearing,whereadecisionwillbemadeonyourapplication
• toarrangeforthepersontoattendthehearing
• toadviseQCATifthepersonhassignedanenduringpowerofattorneyoranadvance health directive
• toinformQCATiftheadult’scircumstanceschangeafteryou’vesubmittedtheapplication.
• Whatwillhappenwhenthetribunalreceivestheapplication?
• QCATstaffwillsendyouanacknowledgmentthatyourapplicationhasbeenreceived.
• Theymaycontactyou,andotherswhoareinvolved,todiscusstheapplication.
• Theywillsetadateforthehearing.
• Theywillsendanoticeofthedate,timeandvenueofthehearingtoyou,thepersonandeveryoneelsenamedintheapplicationasinterestedpersons(inthesectioncalled‘Informationaboutanyoneelseconcerned’).
• Whoattendsthehearing?
All the following will be advised of the hearing and can atttend:
• theadult–asthepersonmakingtheapplication
• theapplicant(ifsomeoneotherthantheadult)
• membersoftheadult’sfamily
• anyoftheadult’sprimarycarers
• allcurrentguardians,administratorsandattorneysfortheadult
• theAdultGuardian
• thePublicTrustee
• anyoneelsewhohasaninterestintheadultorisgivenpermissionbyQCATtoattend.
Itisimportantthattheadultattend.ThisisbecauseQCATwillbebetterabletogaugetheirneedsand rights if they can see him/her.
• CanIwithdrawtheapplication?
You can apply to the tribunal to withdraw the application by making an application under form 40 — Application for miscellaneous matters.
Ifyouhaveanyqueriesaboutapplyingtothetribunaltowithdrawyourapplication,youshouldtalktostaffatthetribunal.Phone1300753228.
• WherecanIgoforhelpwiththisapplication?
Ifyouareuncertainaboutanystepsintheprocedureoryouaredoubtfulabouthowtoanswer any of the questions, you should talk to staff at the tribunal.
Instructionsforcompleting(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page1of20
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
IMPORTANT
TheprinciplesofnaturaljusticeandproceduralfairnessrequirethatpartiesbeawareofallmaterialuponwhichQCATwillbaseitsdecision.PartiesarethereforeentitledtoaccesstheapplicationandanymaterialprovidedtoQCAT.Inexceptionalcircumstances,suchaswherethereisriskofphysicalharm,violenceorinterferencewithacurrentinvestigation,apersonmaymakearequestforaconfidentialityorder.ThereisnoguaranteeQCATwillmakeaconfidentialityorder.IfQCATordersthatthematerialbekeptconfidentialitislikelytohavelessweightasotherpartieshavenothadtheopportunitytocomment.IfyourequestthisformbekeptconfidentialandyoudonotprovideanyevidenceofexceptionalcircumstancesforthisorQCATdoesnotmakeaconfidentialityorder,QCATwillnotrelyupon the material.
FormNumber11(version1)Queensland Civil and Administrative Tribunal Act 2009 (section33)
Yes–Whenever this form asks a question about ‘the person’, it means you. Please answer with details about yourself. Go to question 3.
No–Gotoquestion2
1. Areyoumakingthisapplicationonyourownbehalf?
PRELIMINARYDETAILS
QCATmaymakeadeclarationaboutthecapacityofanadult,guardian,administratoror attorney for a matter.
Application for a declaration about capacity – Guardianship and Administration Act 2000
Refer to attached instructions at the front of this applicationpriortofillingoutthisform. Forofficeuseonly
Casenumberandtype:
Adultnumber:
Date:
Registry:
Sentto:
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QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page2of20
3. Whatistheperson’sname?
PRELIMINARYDETAILS (continued)
4. Whatothernamesisthepersonknownby?
5. Whatsexisthisperson?
6. Howoldistheperson?
7. Whatistheperson’sdateofbirth?
Title Given name/s Surname/Family name
Male Female
Day Month Year
BASICINFORMATIONABOUTTHEPERSON
2. Haveyouinformedthepersonaboutthisapplication?
Yes–Howdidhe/sherespond?Pleasedescribebriefly:
No–Whynot?Pleaseexplainbriefly:
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QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page3of20
8. Whataretheperson’scurrentcontactdetails? Givedetailsfortheplacewherethepersonisnowlivingorstaying:
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
PRELIMINARYDETAILS (continued)
9. Isthispersonlivingathis/herpermanentaddress?
Yes – gotoquestion10
No – pleasewritetheperson’spermanentaddressandcontactdetailshere:
10. Whattypeofaccommodationisthis?
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
(hostel, own home, rental property)
BASICINFORMATIONABOUTTHEPERSON(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page4of20
PRELIMINARYDETAILS (continued)
INFORMATIONABOUTTHEPERSON’SALLEGEDIMPAIREDCAPACITY
12. Whatisthecauseoftheperson’sallegedimpairedcapacity? (tick one or more boxes)
acquired brain injury or cognitive disability (as a result of accident, illness or other causes)
intellectual disability (a condition that has affected the person since birth or early childhood)
psychiatric disability/mental illness (adiagnosedconditionsuchasschizophreniaorbi-polaraffectivedisorder)
dementia (mentalconfusionduetoaconditionsuchasAlzheimer’sdisease,senilityorsomeotherdegenerativedisease)
other (anyotherconditionthatreducestheabilitytomakedecisionsaboutpersonalorfinancialmatters).Givedetails:
BASICINFORMATIONABOUTTHEPERSON(continued)
11. Pleaseidentifytheperson’sculturalbackground
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QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page5of20
INFORMATIONABOUTTHEPERSON’SALLEGEDIMPAIREDCAPACITY (continued)
13. Haveyouobtainedanyreportsbymedical,psychiatricorotherprofessionalsthatgivedetailsoftheperson’sallegedimpairedcapacity?
No – you will need to obtain such a report and attach it to this form.
Yes – pleasegivethefollowingdetailsaboutthewriterofthereport,andattachthereporttothisform (there is room for details about two reports)
Writeroffirstreport
Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Professionalcapacity:
Haveyouattachedthisreport?
Yes
No – Please explain why not and howQCATcanobtainacopy:
PRELIMINARYDETAILS (continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page6of20
Writerofsecondreport(if available)
Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Professionalcapacity:
Haveyouattachedthisreport?
Yes
No – please explain why not and howQCATcanobtainacopy:
INFORMATIONABOUTTHEPERSON’SALLEGEDIMPAIREDCAPACITY (continued)
PRELIMINARYDETAILS (continued)
PRIORITY
14. Isthisapplicationurgent?Thatis,dothemattersdetailedinthisapplicationposeanimmediateproblem?
No
Yes–pleasegivereasons:
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QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page7of20
INFORMATIONABOUTANYGUARDIANS,ADMINISTRATORSORATTORNEYS
15. Hasthepersongivenanyoneenduringpowerofattorneyforpersonal/financialmattersormadeanadvancehealthdirective?
No
Unsure–pleasegivecontactdetailsofanyonewhomightknow:
Yes–Attachcopiesoftherelevantforms(‘Enduringpowerofattorney’or‘Advancehealthdirective’) ifavailable,andgivethefollowingdetailsabouttheattorney/s:
Attorney 1Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to adult
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
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QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page8of20
Attorney 2 (if there is more than one)
Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to adult
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYGUARDIANS,ADMINISTRATORSORATTORNEYS
15. Hasthepersongivenanyoneenduringpowerofattorneyforpersonal/financialmattersormadeanadvancehealthdirective?(continued)
INFORMATIONABOUTTHEAPPLICATION
16. Whoisthepersonwhosedecision-makingcapacityyouareaskingQCATtodeclare?(please tick one box)
self
an adult
a guardian
an administrator
anattorneyforfinancialmatters
an attorney under an advance health directive
an attorney for personal matters
a statutory health attorney
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page9of20
INFORMATIONABOUTTHEAPPLICATION(continued)
17. Whatmatterdoesthisdeclarationofcapacityconcern? Pleasegivedetailsaboutthematter:
18. Whydoyoubelievethatthepersonnamedinquestion3has/doesnothavethecapacitytomakedecisionsinrelationtothismatter? Pleaseexplainbriefly:
19. Whydoyoubelievethatthisdeclarationofcapacityisnecessary? Pleaseexplainbriefly:
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page10of20
INFORMATIONABOUTANYONEELSECONCERNED
Inthissection,yougivedetailsaboutanyonewithaninterestinthisapplication,eventhosewhoopposeit.Thiswouldbeanyonewithaninterestintheperson,suchas:theperson’sprimarycarer,membersoftheperson’sfamily(e.g.spouse,defactoormarried;children,stepchildren,adoptedchildrenorfoster-childrenwhoare18orover;parents,step-parentsorfosterparents;siblings,step-siblings,adoptedsiblingsandfoster-siblingswhoare18orover),serviceproviders,(e.g.respitecarersandcommunitynurses),andclosefriends.Ifyouareunabletogivean address, you may suggest a way to contact the person.
20. Doesanyoneelsehaveaninterestinthisapplication?
No
Yes–Give details in the spaces below. Iftherearemorethaneightpeople,pleaselistonaseparatesheetofpaper.
Other person 1Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page11of20
Other person 2Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page12of20
Other person 3Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page13of20
Other person 4Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page14of20
Other person 5Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page15of20
Other person 6Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page16of20
Other person 7Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page17of20
Other person 8Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
Whatistheattorney’sattitudetothisapplicationlikelytobe?
support
does not support
don’tknow
INFORMATIONABOUTANYONEELSECONCERNED(continued)
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page18of20
PERSON’SREQUIREMENTSATTHETRIBUNALHEARING
This section deals with any requirements that the person may have while attending QCAT hearing.
21. Isaninterpreterrequired?
Yes No
22. Isthepersondeaf?
Yes No
23. Doesthepersonhaveahearingimpairment?
Yes No
24. Doesthepersonhaveimpairedvision?
Yes No
25. Doesthepersonuseamobilityaid?
Yes No
26. Doesthepersonhaveanyotherrequirements?
Yes No
IfYES,pleasespecifylanguage
If YES, what assistance is requested?
If YES, what assistance is requested?
If YES, what assistance is requested?
IfYES,pleaseexplainbriefly
If YES, what assistance is requested?
Note:QCATwillprovidecommunicationassistanceforthepersonwhereverpossible.
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page19of20
BASICINFORMATIONABOUTYOU,THEAPPLICANT
27. Areyoumakingthisapplicationonyourownbehalf?
Yes–goto‘Declarationbytheapplicant’.
No–pleasegiveyournameandcontactdetailshere:
Name
Title Given name/s Surname/Family name
Address
Postcode
Telephone ( ) ( )Daytime phone Mobile phone After hours number (if different)
Fax ( )
Relationship to person
For more information on QCAT: Call 1300 753 228 or visit www.qcat.qld.gov.au
QCATQueensland Civil and Administrative Tribunal
Application for a declaration about capacity –Guardianship and Administration Act 2000 –page20of20
Pleasereadthroughthisapplicationtocheckthatnothinghasbeenoverlookedandthatallthenecessarydocumentsareattached.Thensigntheapplicationbelow.
LODGEMENTDETAILS
Deliverto: Mailto: Faxto: Emailto:
Queensland Civil and Administrative TribunalFloor9,259QueenStreetBrisbaneQld4000 or at any local Magistrates Court
Queensland Civil and Administrative TribunalGPOBox1639BrisbaneQld4001
(07)32219156 [email protected]
Warning
Section216oftheQueensland Civil and Administrative Tribunal Act 2009 makes it an offence for a person to knowingly give the registry documents containing false or misleading information.
Maximumpenaltyforsuchanoffence–$10,000.
SIGNANDDATEHERE
The information in this application is true to the best of my knowledge.
Applicant/ssignhere Date