My Hospital Form

Introduction

The Hospital Form is designed for family and other caregivers of adults with intellectual and developmental disabilities. In the event of a hospital admission, this form communicates essential information to hospital staff, including medical information, substitute decision-maker contacts and information about support needs. It promotes the accommodation of a person’s unique communication and behavioural support needs in health care. It is recommended to prepare this form in advance of an emergency and have it available upon a transfer to the hospital.

Download: Hospital Form Leave us your feedback

Materials
Version history

How to prepare for a COVID-19 hospital visit

Information on Substitute Decision Making

According to the Ontario Health Care Consent Act, a substitute decision-maker is required when someone admitted to hospital is unable or too sick to make health care decisions on their own. Speak Up Ontario provides information on how to identify a substitute decision-maker in Ontario. Look for similar information in other jurisdictions.

For information on Power of Attorney, visit the Office of the Public Guardian and Trustee at the Ministry of Ontario. This information will not apply to other jurisdictions.

This tool was originally developed as the COVID019 Hospital Transfer Form , in response to the COVID-19 Pandemic by the Developmental Disabilities Primary Care Program of Surrey Place, Toronto, 2020. The content of this tool was subject to review by Surrey Place clinicians, primary care providers and other relevant stakeholders. Special acknowledgement of the invaluable contributions by Dr. Yona Lunsky, Director of the Azrieli Adult Neurodevelopmental Centre, and Senior Scientist at the Centre for Addiction and Mental Health, Toronto, and Dr. Ullanda Niel, family physician with special training in the care of adults with developmental disabilities from Queen’s University.

Materials
How to prepare for a COVID-19 hospital visit
- Information on Substitute Decision Making
  
  According to the Ontario Health Care Consent Act, a substitute decision-maker is required when someone admitted to hospital is unable or too sick to make health care decisions on their own. Speak Up Ontario provides information on how to identify a substitute decision-maker in Ontario. Look for similar information in other jurisdictions.
  
  For information on Power of Attorney, visit the Office of the Public Guardian and Trustee at the Ministry of Ontario. This information will not apply to other jurisdictions.
Version history

This tool was originally developed as the COVID019 Hospital Transfer Form , in response to the COVID-19 Pandemic by the Developmental Disabilities Primary Care Program of Surrey Place, Toronto, 2020. The content of this tool was subject to review by Surrey Place clinicians, primary care providers and other relevant stakeholders. Special acknowledgement of the invaluable contributions by Dr. Yona Lunsky, Director of the Azrieli Adult Neurodevelopmental Centre, and Senior Scientist at the Centre for Addiction and Mental Health, Toronto, and Dr. Ullanda Niel, family physician with special training in the care of adults with developmental disabilities from Queen’s University.

All rights reserved. No part of this website may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright owner, Surrey Place. Contact the Developmental Disabilities Primary Care Program at Surrey Place at ddpcp@surreyplace.ca for permission to adapt information and tools to your local practice setting.

My Hospital Form

My Hospital Form

Introduction

Related Guidelines

Related Tools

Share

How to prepare for a COVID-19 hospital visit

How to prepare for a COVID-19 hospital visit

Join Us for the DDPCP Forum: Advancing Inclusive Healthcare!