Utah Supported Decision‐Making Agreement: Template

Looking for the instructions? Information and instructions

Step 1 of 7

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Your Name(Required)

Enter the first and last name of the adult with a disability.

First Last

Your Email Address(Required)

PART 1 – Qualifying Adult with a Disability

I am at least 18 years old (or I will be at least 18 years old when this document is signed)(Required)

Yes

You have to be 18 years old (or you will be at least 18 years old when this document is signed)

I have a disability(Required)

Yes

This form is for adults with a disability

PART 2 – Supporter(s)

In this section you will provide information about Supporter(s). You can have as many supporters as you want. This tool allows you to have up to two. If you want to include more than two supporters, begin the intake process to apply for our services and get help creating your agreement.

How many supporters will you have?

1 Supporter

2 Supporters

Supporter 1

Supporter's name(Required)

First Last

Supporter's address(Required)

Street Address City State ZIP Code

Supporter 2

Supporter's name(Required)

First Last

Supporter's address(Required)

Street Address City State ZIP Code

What will your supporter(s) help with?(Required)

Your supporter(s) can help you with life decisions. Check the life decisions below that your supporter(s) can help you with.

Obtaining food, clothing and a place to live

My physical health

My mental health

Managing my money or property

Getting an education or other training

Choosing and maintaining my services and supports

Finding a job

Other

Other help(Required)

What life decisions not listed above will your supporter(s) help you with?

How I Want Help

Supporter may work with other Supporters(Required)

Yes

Name of other Supporter(s):(Required)

Supporter may share information with other Supporters(Required)

Yes

Name of the Supporter(s)(Required)

Information or document Supporter can share:

Give me information in a way I can understand(Required)

Yes

Be with me when obtaining information about my decision(Required)

Yes

Discuss the good and bad of a choice(Required)

Yes

Help me advocate for my decision(Required)

Yes

Help me tell others my choice(Required)

Yes

Help with other?(Required)

Yes

Please describe(Required)

I really want help with or do not want help with (optional):

PART 3 – Access to Information

I know certain documents may give my Supporters more authority in my life or access to my personal information. I am including those documents as part of this agreement:

Authorization for Release of Records (allows for sharing of information with a party generally)(Required)

Yes

Protective Order (a judge says I have to stay away from someone or someone has to stay away from me)(Required)

Yes

Health Insurance Portability and Accountability Act (HIPAA) Release (allows my doctor to share information with a person I choose)(Required)

Yes

Educational Surrogate Authorization (a trained volunteer appointed by a state or school district to legally represent a child with disabilities in the special education process when parents are unknown, unavailable, or parental rights are terminated)(Required)

Yes

Family Educational Rights and Privacy Act (FERPA) Release (allows my teacher or school to share information with a person I choose)(Required)

Yes

Trust Documents (a legal paper allowing another person to take care of money or things for you)(Required)

Yes

Health Care Representative Authorization (gives my permission to someone else to make some or all medical decisions for me if something happens)(Required)

Yes

Letters of Guardianship or Conservatorship (Court document that gives someone authority to make decisions for you)(Required)

Yes

Please select(Required)

Temporary

Permanent

Living Will/Advanced Directive, including Psychiatric Advanced Directive (tells doctors what kind of treatment I do and don't want and who I want to make decisions for me if I can't)(Required)

Yes

Representative Payee Authorization (a person Social Security asks to take care of your SSI or SSDI for you)(Required)

Yes

Power of Attorney (gives my permission to another person to make some decisions for me)(Required)

Yes

Any Other Release(Required)

Yes

PART 4 – Conflict of Interest

If my Supporter has a family, friend, or financial relationship that could make it hard for them to help me make the best decision for me, I want them to:

Talk to me(Required)

Yes

Withdraw as my Supporter(Required)

Yes

Have another Supporter help me make the decision(Required)

Yes

Other(Required)

Yes

Please describe(Required)

Part 5 - Rights and Responsibilities

Your Rights

I can talk to an attorney before I sign this agreement
My Supporter cannot make decisions for me
My Supporter is not responsible for decisions I make unless they don't tell me something I need to know or knowingly do something wrong
I can end or change this agreement when I want to. I must let my Supporters know about any changes I make to this agreement. Anyone with a copy of the agreement should get a copy of the change in writing.
I can change my Supporters when I want to.
My Supporter(s) can quit if he/she/they want to.
I am signing this supported decision-making agreement because I want people to help me make choices
I can ask anyone I want to be part of any conversation
I can ask anyone I want to be part of any conversation what this agreement does and what it means
No one made me sign this agreement
I do not have to sign this agreement
I know this agreement can stop if another legal document says someone else can make decisions for me. I know it can also be stopped by a judge.

Did you read and understand your rights and responsibilities?(Required)

Yes, I read and understand.

No, I did not understand.

In order to continue, you must read and understand your rights and responsibilities above.

PART 6 – Legal Decision Maker

If this agreement includes an area in which a court says another person can make decisions for me, I or my Supporter will give the person enough time to be part of any conversation about that area. I or my Supporter will tell the person about the discussion and how to participate at least 14 (fourteen) days before by:

Call(Required)

Yes

Email(Required)

Yes

Text(Required)

Yes

Other(Required)

Yes

Please Describe(Required)

The Disability Law Center

The Disability Law Center (DLC) is a private, non-profit organization, designated by the governor as Utah’s Protection and Advocacy agency. The DLC believes in a society where abilities, rather than disabilities, are recognized; all people have an equal opportunity to participate; and where all people are treated with equity, dignity, and respect. We work toward our vision by enforcing and advancing the legal rights, choices, and opportunities of Utahns with disabilities. DLC services are available free of charge statewide, regardless of income, legal status, language, or place of residence.

If you have further questions, please contact us. Even though our focus is on cases that can help as many people as possible – because time and resources are limited – we at least offer information and/or referral options to everyone who contacts us. Materials are also available in alternative formats such as audio, large-print, Braille and Spanish. Call (800) 662-9080 or apply for help online, and our staff will contact you within 5 business days.

Utah Supported Decision‐Making Agreement: Template

Table of Contents

PART 1 – Qualifying Adult with a Disability

PART 2 – Supporter(s)

Supporter 1

Supporter 2

How I Want Help

PART 3 – Access to Information

PART 4 – Conflict of Interest

Part 5 - Rights and Responsibilities

Your Rights

PART 6 – Legal Decision Maker

The Disability Law Center

Utah Supported Decision‐Making Agreement: Information and instructions

Guardianship and Alternatives Presentation

Supported Decision-Making

Supported Decision-making and Guardianship Comparison

Requirements for Supported Decision-making Agreements Legislation

Disability Benefits Explainer

Self-determination and Guardianship

Automatic

Resources

Apply for Help

Utah Supported Decision‐Making Agreement: Template

Table of Contents

PART 1 – Qualifying Adult with a Disability

PART 2 – Supporter(s)

Supporter 1

Supporter 2

How I Want Help

PART 3 – Access to Information

PART 4 – Conflict of Interest

Part 5 - Rights and Responsibilities

Your Rights

PART 6 – Legal Decision Maker

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Resources

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