Ulysses AgreementCare, 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:
My symptoms (early symptoms):
Plan of action:
Care of my child/ren: (refer to addendum for information on each child)
Addendum to the Ulysses AgreementInformation re: <insert name of child>
Date of birth:
Personal Health Care Number:
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 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 <print name>: <signature>
Signature of all members of the support team: