Deprivation of liberty form

Person's name

First name

Last name
Gender
Date of birth
Previous address of individual including postcode

Medical history
Relevant medical history

Including diagnosis of mental disorder if known
Sensory loss
HearingVision
Communication needs
Non verbalLimitedBSLOther
If other please state
Name and address of the care home or hospital
Telephone number
Date of admission
Length of placement
Person to contact at the care home or hospital
including ward details if appropriate
Name

First name

Last name
Telephone
Email
Ward

if appropriate
Usual address of person

If different from above
Telephone number

Funding
How is the care funded
Local authorityNHSJoint local authority and NHSSelf fundedInsurance or other
If funded by local authority, please specify

Request for a Standard Authorisation
Date from which the standard authorisation is required

If standard only - within 28 days. If urgent authorisation is also attached - within 7 days.
Purpose of the standard authorisation

• Please describe the care and / or treatment this person is receiving or will receive day-to-day and attach a relevant care plan. • Please give as much detail as possible about the type of care the person needs, including personal care, mobility, medication, support with behavioural issues, types of choice the person has and any medical treatment they receive. • Is medication being administered covertly? • Is there a best interest decision which details this?
Explain why the person is or will not be free to leave and why they are under continuous or complete supervision and control.

• Describe the proposed restrictions or the restrictions you have put in place which are necessary to ensure the person receives care and treatment. (It will be helpful if you can describe why less restrictive options are not possible including risks of harm to the person.) • Indicate the frequency of the restrictions you have put in place.
Proposed restrictions
Locked internal and external doorsWindow restrictorsAlaramed fire doorsSecure garden areaCCTV internally/externallyWheelchair lap strapShower chair lap strapBath hoist lap beltBed rails/bumpersRecliner chairFull body hoistSensors - Mat/motion/chair alarm/bed alarmDoor sensorAudio/video monitoring systemSafe-hold techniquesSedative medication1:1/2:1 community accessConstant supportAdditional 1:1/2:1 supportBod suitVisiting restrictions (i.e. meal times, during the day/night, safeguarding, etc)Weighted blanket – often used for restless legs syndromeBedroom door lockPersonal careCovert medicationOther
If covert medication please give date authorised
If additional support, please specify

Such as 1:1, 2:1, 3:1
If other, please specify

Interested persons and others to consult
Is there anybody involved in the person's care?
YesNo
Family member or friend
Name

First name

Last name
Relationship
Address
Email
Telephone
Anyone named by the person as someone to be consulted about their welfare.
Name

First name

Last name
Address
Telephone
Anyone engaged in caring for the person or interested in their welfare.
Name

First name

Last name
Address
Telephone
Any donee of a Lasting Power of Attorney granted by the person
Health and welfare
YesNo
Finance
YesNo
Name

First name

Last name
Relationship
Address
Telephone
Any personal welfare deputy appointed for the person by the Court of Protection
Name

First name

Last name
Address
Telephone
Any IMCA instructed in accordance with sections 37 to 39D of the Mental Capacity Act 2005
Address
Telephone

Whether it is necessary for an Independent Mental Capacity Advocate
Apart from professionals and other people who are paid to provide care or treatment, this person has no-one whom it is appropriate to consult about what is in their best interestsThere is someone whom it is appropriate to consult about what is in the person’s best interests who is neither a professional nor is being paid to provide care or treatment
Whether there is a valid and applicable advance decision
The person has made an Advance Decision that is valid and applicable to some or all of the treatmentThe Managing Authority is not aware that the person has made an Advance Decision that may be valid and applicable to some or all of the treatmentThe proposed deprivation of liberty is not for the purpose of giving treatment
The person is subject to some element of the Mental Health Act 1983
If yes, please describe further

Application/order/direction, community treatment order, guardianship

Other relevant information
Names and contact numbers of regular visitors not detailed elsewhere on this form:
Any other relevant information including safeguarding issues

Confirmation
Your name

First name

Last name
Date
Time
I have informed any interested persons of the request for a DoLS Authorisation
Yes

Characteristics of the person
Racial, ethnic or national origin
WhiteMixed/multiple ethnic groupsAsian/Asian BritishBlack/Black BritishNot statedUndeclared/not knownOther
If other, please specify
The person's sexual orientation
Straight or HeterosexualGay or LesbianBisexualOther sexual orientationOther sexual orientation
Disability
Physical disability: Hearing impairmentPhysical disability: Visual impairmentPhysical disability: Dual sensory lossPhysical disability: OtherMental health needs: DementiaMental health needs: OtherLearning disabilityOther disability (none of the above)No disability

While the person must have a mental disorder as defined under the Mental Health Act 1983, there may be another disability that is primarily associated with the person. This is based on the primary client types used in the Adult Social Care returns. To monitor the use of DoLS, the HSCIC requests information on other disabilities associated with the individual concerned. The presence of “other disability” may be unrelated to an assessment of mental disorder or lack of capacity.
Religion
NoneNot statedBuddhistHinduJewishMuslimSikhAny other religionChristian (includes Church of England, Catholic, Protestant and all other Christian denominations)
Do you need to grant an Urgent Autorisation because it appears to you the the Deprivation of Liberty is already occuring or about to occur, and you reasonably think all of the following conditions are met

Urgent authorisation
Please select to confirm that the person appears to meet that particular condition.
The person is aged 18 or overThe person is suffering from a mental disorderThe person is being accommodated here for the purpose of being given care or treatment. Please describe further belowThe person lacks capacity to make their own decision about whether to be accommodated here for care or treatmentThe person has not, as far as the Managing Authority is aware, made a valid Advance Decision that prevents them from being given any proposed treatmentAccommodating the person here, and giving them the proposed care or treatment, does not, as far as the Managing Authority is aware, conflict with a valid decision made by a donee of a Lasting Power of Attorney or Personal Welfare Deputy appointed by the Court of Protection under the Mental Capacity Act 2005It is in the person’s best interests to be accommodated here to receive care or treatment, even though they will be deprived of libertyDepriving the person of liberty is necessary to prevent harm to them, and a proportionate response to the harm they are likely to suffer otherwiseThe person concerned is not, as far as the Managing Authority is aware, subject to an application or order under the Mental Health Act 1983 or, if they are, that order or application does not prevent an Urgent Authorisation being givenThe need for the person to be deprived of liberty here is so urgent that it is appropriate for that deprivation to begin immediately before the request for the Standard Authorisation is made or has been determined

An urgent authorisation is now granted
It is to be in force for 7 days.

The maximum period allowed is 7 days.
This urgent authorisation will expire at the end of the day on:
Name

First name

Last name
Date
Time

Request for an extension to the urgent authorisation
If supervisory body is unable to complete the process to give a Standard Authorisation (which has been requested) before the expiry of the existing Urgent Authorisation
An Urgent Authorisation is in force and a Standard Authorisation has been requested for this person.
The Managing Authority now requests that the duration of this Urgent Authorisation is extended for a further period of days
It is essential for the existing deprivation of liberty to continue until the request for a Standard Authorisation is completed because the person needs to continue to be deprived and exceptional reasons are as follows (please record your reasons):
Due to the need to provide a full and comprehensive assessment of circumstances which is not yet complete, it is necessary to extend the urgent authorisation as the managing authority considers that there is currently a Deprivation of Liberty occurring
Name

First name

Last name
Date
Record that the duration of this urgent authorisation has now been extended
This part of the form must be completed by the supervisory body if the duration of the Urgent Authorisation is extended. The Managing Authority does not complete this part of the form.
The duration of this Urgent Authorisation has been extended by the Supervisory Body.
It is now in force for a further days

Important note: The period specified must not exceed seven days.
This Urgent Authorisation will now expire at the end of the day on
Name

First name

Last name

On behalf of the Supervisory Body
Date
Time

Thank you for completing this form, please now submit it.

Deprivation of liberty form

Additional information