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: