DEPRIVATION OF 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) ☐ Full name of person being Sex : deprived of liberty Date of Birth Est. Age : (or estimated age if unknown) Relevant Medical History Sensory Loss Communication Requirements Name and address of the care home or hospital requesting this authorisation Telephone Number Person to contact at the Name care home or hospital, (including ward details if Telephone appropriate) Email Ward (if appropriate) Present 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 Local Authority NHS ☐ ☐ please specify Local Authority and Self funded ☐ ☐ NHS (jointly funded) by person Funded through ☐ insurance or other REQUEST FOR STANDARD AUTHORISATION
DEPRIVATION OF 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) ☐ Full name of person being deprived of liberty Sex : Date of Birth (or estimated age if unknown) Est. Age : Relevant Medical History 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) Present 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 Local Authority please specify ☐ NHS ☐ Local Authority and NHS (jointly funded) ☐ Self funded by person ☐ Funded through insurance or other ☐ REQUEST FOR STANDARD AUTHORISATION
Form_1_Standard_and_Urgent_Request_Alt__2_.docx