Case ID Number: NHS Number: DEPRIVATION OF LIBERTY SAFEGUARDS FORM 1 REQUEST FOR STANDARD AUTHORISATION AND URGENT AUTHORISATION Request a Standard Authorisation only (you DO NOT need to complete pages 6 or 7) Grant an Urgent Authorisation (please ALSO complete pages 6 and 7 if appropriate/required) Full name of person being deprived of liberty Sex Date of Birth (or estimated age if unknown) Est. Age Relevant Medical History (including diagnosis of mental disorder if known) Sensory Loss Communication Requirements Name and address of the care home or hospital requesting this authorisation Telephone Number Person to contact at the care home or hospital, (including ward details if appropriate) Name Telephone Email Ward (if appropriate) Usual address of the person, (if different to above) Telephone Number Name of the Supervisory Body where this form is being sent How the care is funded Authority please specify NHS Authority and NHS (jointly funded) Self-funded by person Funded through insurance or other
INFORMATION ABOUT INTERESTED PERSONS AND OTHERS TO CONSULT Family member or friend Name Relationship to relevant person Address Telephone Family member or friend Name Relationship to relevant person Address Telephone Family member or friend Name Relationship to relevant person Address Telephone Family member or friend Name Relationship to relevant person Address Telephone Anyone named by the person as someone to be consulted about their welfare Name Relationship / Professional role Address Telephone Anyone engaged in caring for the person or interested in their welfare Name Relationship / Professional role Address Telephone
Christian (includes Church of Wales, Catholic, Protestant and all other Christian denominations) ONLY COMPLETE THIS SECTION IF YOU NEED TO AN URGENT AUTHORISATION BECAUSE IT APPEARS TO YOU THAT THE DEPRIVATION OF LIBERTY IS ALREADY OCCURING, OR ABOUT TO OCCUR, AND YOU REASONABLY THINK ALL OF THE FOLLOWING CONDITIONS ARE MET URGENT AUTHORISATION Place a cross in EACH box to confirm that the person appears to meet the particular condition The person is aged 18 or over The person is suffering from a mental disorder The person is being accommodated here for the purpose of being given care or treatment. Please describe further on page 2 The person lacks capacity to make their own decision about whether to be accommodated here for care or treatment The person has not, as far as the Managing Authority is aware, made a valid Advance Decision that prevents them from being given any proposed treatment Accommodating the person here, and giving them the proposed care or treatment, does not, as far as the Managing Authority is aware, conflict with a valid decision made by a donee of a Lasting Power of Attorney or Personal Welfare Deputy appointed by the Court of Protection under the Mental Capacity Act 2005 It is in the person’s best interests to be accommodated here to receive care or treatment, even though they will be deprived of liberty Depriving the person of liberty is necessary to prevent harm to them, and a proportionate response to the harm they are likely to suffer otherwise The person concerned is not, as far as the Managing Authority is aware, subject to an application or order under the Mental Health Act 1983 or, if they are, that order or application does not prevent an Urgent Authorisation being given The need for the person to be deprived of liberty here is so urgent that it is appropriate for that deprivation to begin immediately before the request for the Standard Authorisation is made or has been determined AN URGENT AUTHORISATION IS NOW GRANTED This Urgent Authorisation comes into force immediately. It is to be in force for a period of: days The maximum period allowed is seven days. This Urgent Authorisation will expire at the end of the day on: