Carers identified?

Sample 1: Blank Ulysses Agreement and Addendum

Page last updated: 2010

Ulysses Agreement

Care, treatment and personal management plan for <insert name>

Updated: <insert date>

This is an agreement between the following people and myself, <insert name> of <insert address and phone>.

List names, addresses and phone numbers of those people involved:

Purpose:

My symptoms (early symptoms):

Plan of action:

Medication:

Medical records:

Care of my child/ren: (refer to addendum for information on each child)

Cancellation:

Addendum to the Ulysses Agreement

Information re: <insert name of child>

Date of birth:

Personal Health Care Number:

Family doctor:

Pediatrician:

Daycare/childcare setting (and phone):

Preschool/school (and phone):

Specific information I wish known about this child: (such as special needs, allergies, security objects, typical daily routine) Top of page

Periodic review of Agreement

A review of this agreement shall take place every 6 months or as necessary. If this agreement has been put into action, then a review should take place as soon as possible after I am stabilised.

Signature of <print name>: <signature>

Date:

Signature of all members of the support team: