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 Sex deprived of liberty Date of Birth (or estimated age if Est. Age unknown) Relevant Medical History (including diagnosis of mental disorder if known) Communication Sensory Loss Requirements Name and address of the care home or hospital requesting this authorisation Telephone Number Name Person to contact at the Telephone care home or hospital, (including ward details if Email appropriate) 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 Authority please specify Authority and How the care is funded NHS NHS (jointly funded) Self-funded by Funded through person insurance or other
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
DOLS-form-1-standard-and-urgent-request-form.docx.docx