The following is an example of a Ulysses Agreement that is constructed using the basic model. The Agreement was prepared with an actual family and used with success, but the names have been changed to protect confidentiality.
Sample Ulysses AgreementCare, treatment and personal management plan for Mary Grant
Updated: April 3 2006
This is an agreement between the following people and myself, Mary Grant, of 1234 64th Street NW, Prairieville, phone: 987-6543.
- Mrs Roberta Grant (Mary's mother) 403-555-6666
- Dr J Addams (family physician) 403-555-6543
- Carol Noone (friend) 403-555-7777
- Nancy Green (neighbour) 403-55-8888
- Sue Linde (Midtown Mental Health Team) 403-555-4444
- Dr T White (Midtown Mental Health Team) 403-555-4444
- Dan Diamond (alcohol and drug counsellor) 403-555-3333
- Cindy Fox (social worker) 403-555-2222
- Fran Rite (parent education worker) 403-555-1111
- David Grant (son) 403-555-1234
The purpose of this agreement is to provide a clear set of guidelines for actions to be taken by my support team if I exhibit any signs of my illness as outlined below. I appoint Roberta Grant, my mother, or in her absence Carol Noone, as overseers of this agreement to ensure that, as far as possible, it is completely implemented. The primary purpose of this agreement is to ensure that my son, Douglas, will be properly cared for with the least amount of disruption in his daily routine. My request is that support be given to my son and me so that I can continue to care for him at home. However, I understand that this may not be possible, and I trust that the people I have named will make good decisions, if necessary, for the care of my child if I experience a relapse of my illness.
My symptoms (early symptoms):
- Difficulty falling asleep and staying asleep
- Increased irritability, anxiety and agitation
- Decrease in appetite
- Emotional withdrawal and social isolation
- Impaired judgment regarding money
- Intrusive, irrational thoughts
- Suicidal thoughts
- Hearing voices
- Increased generalised fear and anxiety Top of page
Upon onset of the symptoms of my illness as detailed above, the following actions should be taken by my support team:
- There should be open communication between the members of my support team. Any one of my support team shall speak to me first about their concerns and then contact the Mental Health Team Case Manager.
- The following actions should then be taken:
- My mental health case manager, team doctor, myself and any other members of my support team that I wish to be present, should meet for an assessment of my mental status. Adjustments in medication and a care plan should be established.
- The team will provide increased support through more frequent contact and by advocating for additional needed services, such as homemaking.
- The mental health case manager will contact the social worker to enlist her support and services. Specifically these supports would be a homemaker, increased child care and possible placement of my son if necessary.
- The area counsellor at the school should be informed of my difficulties so as to be responsive to possible difficulties my son may exhibit at school.
- The mental health case manager will contact the friends I have listed to enlist their support.
- If I am abusing substances the mental health team may contact my alcohol and drug counsellor and elicit his support.
- If I am unable to care for my son with the additional support, every effort should be made for my son to be able to remain at home under the care of one of my friends or relatives listed above.
- Attached to this agreement is information important to my child's care.
- Only after all efforts have been made to meet the above plans have been exhausted, will the case manager contact the Ministry of Child and Family Services to arrange respite care.
- If after review and actions as outlined in #1 and #2 have not been effective in stabilising me then I will give consent to admission to the Venture program. Arrangements for the care of my son are outlined below.
- Hospitalisation should be considered as a last resort. Top of page
As long as I remain stable, medications will continue to be dispensed to me on a monthly basis. Should I exhibit any symptoms of illness, this schedule will be reviewed.
I authorise my case manager or doctor to discuss my mental status and current functioning or any other medical information required for decision making with any members of my support team, or any person responsible for my care.
Care for my child:
In regard to my son Douglas, I would like the following to take place:
- If I am not able to care for my son at home, or if I am admitted to Venture or the hospital, I request that Douglas be placed in the care of my mother, Roberta Grant. My mother will need to apply for compensation for the cost of caring for Douglas, and the financial compensation is contingent upon current legislation and policy. I request that Douglas' daily routine be maintained as closely as possible. This includes attending daycare on a regular basis. Please see the attached addendum for information about Douglas' routine and allergies.
- If my mother is unavailable immediately, I request that the Ministry make every attempt to place Douglas in her care as soon as possible. In the interim, Carol Noone or Nancy Green should be contacted regarding their ability to care for Douglas on an emergency short-term basis.
- If I have been admitted to the Venture program or to hospital, I agree not to have contact with Douglas for the first week of admission. Top of page
As a result of my illness I might attempt to cancel this agreement. I only wish to cancel this agreement in the following way:
- I will inform my case manager or doctor at the Mental Health Team that I want to revoke this agreement.
- My own team psychiatrist will assess me. The purpose of this assessment is to ensure that I am not showing symptoms of my illness. I would like another member of my support team to be present. The psychiatrist may consult with another doctor.
- The case manager and I will inform members of my support team of this revocation in writing.
Addendum to the Ulysses AgreementInformation re: Douglas Grant
Personal Health Number:
9am to 3pm Phone:
After school care:
- Douglas is severely allergic to nut products. He is also allergic to dust, feathers, perfume and many other irritants. Caregivers must have an epi pen needle at all times. Douglas carries an inhaler for emergencies and uses Ventalin preventative medication three times per day. Please consult with his family doctor, who knows him very well, about any questions regarding his allergies or treatment.
- Douglas goes to bed at 8pm with light out at 8.30pm. He usually has stories and a light snack before bed. He brushes his teeth immediately after eating.
- Douglas has met several times with Barbara Bean, a family and child therapist with the Midtown Mental Health Team, who has helped him learn about my mental illness and express his feelings about how he has been affected by it. It may be helpful for Douglas to meet again with Barbara to receive more information and support. Top of page
Periodic review of AgreementA 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 Mary Grant:
Signature of all members of the support team: