Case ID Number: DEPRIVATION OF LIBERTY SAFEGUARDS FORM 3 AGE, MENTAL CAPACITY, NO REFUSALS, BEST INTERESTS ASSESSMENTS AND SELECTION OF REPRESENTATIVE This combined form contains 4 separate assessments and includes selection of representative. If any assessment is negative there is no need to complete the others unless specifically commissioned to do so by the Supervisory Body. Please indicate which assessments have been completed (*Supervisory Bodies will vary in practice as to who completes the Mental Capacity Assessment) Age Mental Capacity* No Refusals Best Interests This form is being completed in relation to a request for a standard authorisation This form is being completed in relation to a review of an existing standard authorisation under Part 8 of Schedule A1 to the Mental Capacity Act 2005. Full name of the person being assessed Est. Age Date of birth (or estimated age if unknown) This also constitutes the Age Assessment. If any uncertainty please provide additional information at the end of the form. Name and address of the care home or hospital in which the person is, or may become, deprived of liberty Name of the Assessor Address of the Assessor Profession of the Assessor Name of the Supervisory Body The present address of the person if different from the care home or hospital stated above. In carrying out this assessment I have met or consulted with the following people
Case ID Number: DEPRIVATION OF LIBERTY SAFEGUARDS FORM 3 AGE, MENTAL CAPACITY, NO REFUSALS, BEST INTERESTS ASSESSMENTS AND SELECTION OF REPRESENTATIVE This combined form contains 4 separate assessments and includes selection of representative. If any assessment is negative there is no need to complete the others unless specifically commissioned to do so by the Supervisory Body. Please indicate which assessments have been completed (*Supervisory Bodies will vary in practice as to who completes the Mental Capacity Assessment) Age Mental Capacity* No Refusals Best Interests This form is being completed in relation to a request for a standard authorisation This form is being completed in relation to a review of an existing standard authorisation under Part 8 of Schedule A1 to the Mental Capacity Act 2005. Full name of the person being assessed Date of birth (or estimated age if unknown) Est. Age This also constitutes the Age Assessment. If any uncertainty please provide additional information at the end of the form. Name and address of the care home or hospital in which the person is, or may become, deprived of liberty Name of the Assessor Address of the Assessor Profession of the Assessor Name of the Supervisory Body The present address of the person if different from the care home or hospital stated above. In carrying out this assessment I have met or consulted with the following people
Form-3%20BIA-Combined-Assessments-V3.docx