Case ID Number: Filled in by DoLS Team 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) Correct spelling of names is important Full name of person being Sex deprived of liberty 01/01/1900 Date of Birth Est. Age (or estimated age if unknown) Relevant Medical History (including diagnosis of mental disorder if known) Sensory Loss Communication Requirements Full Name and postcode for future correspondence. Name and address of the care home or hospital requesting this authorisation Telephone Number Contact number (someone the DoLS Team/ BIA assessor can contact to Person to contact at the Name discuss the specific care plan) care home or hospital, (including ward details if Telephone appropriate) Email Ward (if appropriate) In cases of Hospital admission or Respite insert home address of the person Usual address of the person, (if different to above) Please give the name of the funding authority Name of the Supervisory Body where this form is being sent CARE HOMES Local Authority e.g.Gloucestershire County Council please specify How the care is funded If not funded by Gloucestershire, NHS Local Authority and please send application to funding NHS (jointly funded) authority. Self-funded by Funded through person insurance or other
Case ID Number: Filled in by DoLS Team 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 Correct spelling of names is important Sex Date of Birth (or estimated age if unknown) 01/01/1900 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 Full Name and postcode for future correspondence. Telephone Number Contact number Person to contact at the care home or hospital, (including ward details if appropriate) Name (someone the DoLS Team/ BIA assessor can contact to discuss the specific care plan) Telephone Email Ward (if appropriate) Usual address of the person, (if different to above) In cases of Hospital admission or Respite insert home address of the person Name of the Supervisory Body where this form is being sent Please give the name of the funding authority CARE HOMES How the care is funded If not funded by Gloucestershire, please send application to funding authority. Local Authority please specify e.g.Gloucestershire County Council NHS Local Authority and NHS (jointly funded) Self-funded by person Funded through insurance or other