Power of Attorney Capacity Assessment Form
Use this form to document whether a person appears able to understand and grant power of attorney, including their understanding, decision-making ability, observations, and assessment outcome.
Assessment Subject Details
Full Name of Person Being Assessed
*
First Name
Middle Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Title
*
Relationship to Person Being Assessed
Please Select
Self
Family Member
Attorney
Healthcare Provider
Social Worker
Case Manager
Legal Representative
Other
Referral Source or Reason for Assessment
*
Capacity Understanding and Communication
Ability to communicate choices
*
Clearly
With prompting
Limited
Unable
Understanding of the purpose of power of attorney
*
No understanding
1
2
3
4
Fully understands
5
1 is No understanding, 5 is Fully understands
Trusted agent / attorney-in-fact
Ability to explain what authority the agent may receive
*
Cannot explain
1
2
3
4
Explains clearly
5
1 is Cannot explain, 5 is Explains clearly
Limits or instructions to set for the agent
Decision-Making Abilities
Awareness of personal and financial affairs at a general level
*
Very limited
1
2
3
4
5
6
7
8
9
Highly aware
10
1 is Very limited, 10 is Highly aware
Ability to compare the consequences of granting or not granting authority
*
Unable to compare
1
2
3
4
5
6
7
8
9
Able to compare clearly
10
1 is Unable to compare, 10 is Able to compare clearly
Memory and orientation checks
*
Ability to make a consistent choice over the conversation
*
Consistent throughout
Mostly consistent with minor changes
Inconsistent or fluctuating
Unable to determine
Observed signs that may affect capacity
*
Confusion
Coercion
Distress
Intoxication
Fatigue
Hearing or communication difficulty
Memory lapses
None observed
Other
Additional notes on decision-making abilities
Support, Safety, and Observations
Used assistive communication or support from another person
*
No
Yes, assistive communication used
Yes, support from another person
Yes, both assistive communication and support from another person
Any coercion, undue influence, or pressure observed or reported
*
No
Observed
Reported
Observed and reported
Unable to determine
Notes on ability to ask questions and respond appropriately
Clinician/assessor observations of mood, attention, and consistency
Accommodations used during assessment
Plain language explanations
Repeated information or prompts
Extended time
Quiet environment
Written prompts or notes
Interpreter or translated materials
Visual aids
Other
Assessment Outcome and Next Steps
Overall capacity impression for granting power of attorney
*
Appears capable
Unclear
Appears not capable
Recommended next step
*
Proceed
Repeat assessment
Seek additional evaluation
Defer
Summary of key reasons supporting the conclusion
*
Signature of assessor
*
Submit Assessment
Submit Assessment
Should be Empty: