Mental Capacity Assessment Form
for At-Risk Adults

1. Person Being Assessed

Name Date of Birth Assessment Date Assessor Name & Role

2. Assessment Details

Decision to be made Reason for Assessment

3. Capacity Assessment

Is there an impairment or disturbance in the functioning of mind or brain? Yes No If yes, details Can the person: a) Understand information relevant to the decision? Yes No b) Retain that information long enough to make a decision? Yes No c) Use or weigh the information as part of the decision-making process? Yes No d) Communicate their decision (by any means)? Yes No

4. Assessment Outcome

Summary of findings Does the person have capacity to make this decision? Yes No Further comments

5. Assessor Declaration

Name Role Signature Date