1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 2
REQUEST FOR EXTENSION OF URGENT AUTHORISATION
Important note: it is essential that you make any necessary request for an extension promptly. You
can request an extension by completing this form, or orally (e.g. by telephone) or in some other way
(e.g. by email or fax). In all cases, you must give the person being deprived of their liberty, and any
section 39A IMCA acting for them, notice in writing that you have made the request.
PART A — BASIC INFORMATION
CASE
NUMBER
Name
Address
Address
Name
DOB
Est. age
Full name of the person being deprived of their liberty
Their date of birth (or estimated age if unknown)
NameName and address of the hospital or care home
where the person is being deprived of their liberty
d d m m y y y y
PART B — THE REQUEST FOR AN EXTENSION
A standard authorisation has been requested for this person.
An urgent authorisation is in force. This existing urgent authorisation expires
at the end of the day on:
Enter above the date on which the urgent authorisation is due to expire ×
Years
Name
Name and address of the person registered, or
required to be registered, under Chapter 2 of Part 1
of the Health and Social Care Act 2008 in respect of
the provision of residential accommodation, together
with nursing or personal care, in the care home and
in relation to an independent hospital, the person
registered, or required to be registered, under
Chapter 2 of Part 1 of the Health and Social Care
Act 2008 in respect of regulated activities (within the
meaning of that Part) carried on in the hospital, or
the NHS Trust that manages the hospital
Name of the PCT or local authority to whom
this form is being sent (‘the supervisory body’)
Email
Telephone
NamePerson to contact at the hospital or care home
ddm
m
yyyy
