Tick one. The boarding room which the tenant is renting is not shared by other tenants. The boarding room which the tenant is renting is shared by other tenants and the maximum number of other tenants who may occupy the room is .
Tick one. This boarding house tenancy is a joint tenancy with . This boarding house tenancy is not a joint tenancy.
Tick one. Will you be using subcontractors for any part of your contracted work? ☐ Yes ☐ No Write the business name of any subcontractors being used by PCBU2. As evidence of due diligence, attach a copy of your Subcontractor’s SSSP Agreement section, to the back of this SSSP either now or when the Subcontractor begins work on this site. Kākāriki (Green) Agreement SSSP Form 1 3 Outline of work being undertaken Write a brief outline of the scope of work this SSSP relates to.
Tick one. ❑ Yes as a first treatment If yes, how many times? (not more than 9) ❑ Yes only if other treatments have not worked If yes, how many times? (not more than 9) ❑ No Signatures for Advance Consent Direction You must sign here. Signature: Date: Witness 1 must sign here. This person can’t be part of your treating team. Name: Important: Witnesses must not be the Carer, Nominated Person, Power of Attorney or Guardian Signature: Date: Witness 2 must sign here ONLY if you ticked yes to ECT. This person can’t be part of your treating team. Name: Signature: Date: Your treating team member must sign here (most often a GP or psychiatrist): Name: ❑ I am satisfied that the person has decision-making capacity to fill in this form and that the matters discussed and agreed to in the form are within my professional scope of practice. Signature: Date: Contact details: Witness 1 must sign here. This person can’t be part of your treating team. Name: Signature: Date: Witness 2 must sign here ONLY if you ticked yes to ECT. This person can’t be part of your treating team. Name: Signature: Date: Signature Checklist Did you sign this form? Nominated person – signature on Page 4 Yes / No Advance Agreement – signatures on Page 10 Yes / No Advance Consent Direction – signatures on Page 15 Yes / No Where does your Form Kit go? Once your Form Kit is signed, you must give a copy to: Person Given to You Yes / No Your Nominated Person, if you have one Yes / No Your Guardian, if you have one Yes / No Your Power of Attorney, if you have one Yes / No Any clinician who can access your health information Yes / No Any clinician who can’t access your health information Yes / No You may want to give the Form Kit to: Person Distributed Your Carer, if you have one Yes / No Other people who are helping you Yes / No If you are not a patient at Canberra Health Services Mental Health, Justice Health and Alcohol and Drugs Service (MHJHADS), you can email it to XxxxxxxxXxxxxxx@xxx.xxx.xx. They will add it to Canberra Health Services system. Yes / No Other – Name: Yes / No Other – Name: Yes / No Other – Name: Yes / No Your Nominated Person, Advance Agreement or Advance Consent Direction is legal until it is cancelled or changed. This Form Kit has your views, wishes and decisions. Read this Form Kit at least once a year to see if you want to change it.
