Personal Directive

Client Information

Children

Medical Information

Instructions for Personal Directive

If NO, please indicate who you wish to appoint as your Primary Agent below:

Alternate Agent

The Personal Directive takes effect when I lack capacity as determined by:

My Personal Directive comes into effect when I lack capacity to make my own decisions, determined as follows: (please check one)

Any general instructions can be given (for example: a person may say that they want to live independently as long as possible; or that they do not want to live with a particular person).