How to use this: Fill this out together as a family — ideally before a crisis, not during one.
Assign a name to every row. "Everyone" means no one. Review and update every 3 months as needs change.
Keep a copy where all family members can find it.
Patient name
Date completed
Next review date
Family members present at this meeting
CARE RESPONSIBILITIES — Assign one primary owner per task. Add a backup.
| Task | Primary owner | Backup person | How often | Notes / how it's done |
|---|---|---|---|---|
| Medical appointments (booking, attending) | ||||
| Medication management | ||||
| Grocery shopping / meal planning | ||||
| Cooking / meal preparation | ||||
| Financial oversight (bills, banking) | ||||
| Home maintenance | ||||
| Daily check-in call | ||||
| Weekly in-person visit | ||||
| Personal care support (bathing, dressing) | ||||
| Care coordinator / agency contact | ||||
| Respite scheduling for primary caregiver | ||||
| Legal documents oversight (POA, Rep. Agreement) | ||||
| Driving / transportation | ||||
| Social activities / outings | ||||
| Emergency response (primary contact) | ||||
| Other: |
DECISION-MAKING PROTOCOL
Who makes day-to-day care decisions?
Who makes major medical decisions? (check POA / Rep. Agreement)
How do we handle disagreements between family members?
What triggers us to call a family meeting? (who calls it, how much notice?)
KEY CONTACTS & INFORMATION
Family doctor
Name: ___________________
Phone: ___________________
Clinic: ___________________
Phone: ___________________
Clinic: ___________________
Home care agency / coordinator
Agency: __________________
Coordinator: ______________
Phone: ___________________
Coordinator: ______________
Phone: ___________________
Fraser Health case manager
Name: ___________________
Phone: ___________________
Access Line: 1-877-935-5669
Phone: ___________________
Access Line: 1-877-935-5669
Pharmacy
Name: ___________________
Phone: ___________________
Address: _________________
Phone: ___________________
Address: _________________
Nearest hospital / emergency
Hospital: ________________
Address: _________________
Emergency: 911
Address: _________________
Emergency: 911
Legal — POA / Representation Agreement
Document location: ________
Lawyer: __________________
Phone: ___________________
Lawyer: __________________
Phone: ___________________
LEGAL DOCUMENTS STATUS
Power of Attorney
☐ In place ☐ Needed
Holder: ________________
Holder: ________________
Representation Agreement (BC)
☐ In place ☐ Needed
Holder: ________________
Holder: ________________
Advance Directive / DNR
☐ In place ☐ Needed
Location: _______________
Location: _______________
Will
☐ In place ☐ Needed
Lawyer: ________________
Lawyer: ________________
Important: In BC, a Representation Agreement must be in place while your parent still has capacity to sign it. If capacity is lost before this document exists, the process becomes significantly more complicated and costly. If this isn't done yet — do it now. · Free care navigation call: gurjotnarwal.com/how-i-can-help