Case ID 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 page 7) Grant an Urgent Authorisation (please ALSO complete pages 7 if appropriate/required) Full name of person being Sex deprived of liberty Date of Birth Est. Age (or estimated age if unknown) Relevant Medical History (including diagnosis of mental disorder if known) Name and Address of GP Practice Sensory Loss Communication Requirements Name and address of the Care Home or Hospital requesting this authorisation Telephone Number Yes/No Is this a short term care arrangement (Respite Care) If Yes expected end date: – Person to contact at the Name care home or hospital, (including ward details if Telephone appropriate) Email Ward (if appropriate) Home address of the person, being deprived of their liberty (before they moved into a care/nursing home) Telephone Number Name of the Supervisory Body where this form is being sent
Case ID 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 page 7) Grant an Urgent Authorisation (please ALSO complete pages 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) Name and Address of GP Practice Sensory Loss Communication Requirements Name and address of the Care Home or Hospital requesting this authorisation Telephone Number Is this a short term care arrangement (Respite Care) Yes/No If Yes – expected end date: Person to contact at the care home or hospital, (including ward details if appropriate) Name Telephone Email Ward (if appropriate) Home address of the person, being deprived of their liberty (before they moved into a care/nursing home) Telephone Number Name of the Supervisory Body where this form is being sent