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
2
The managing authority now requests that the duration of this urgent authorisation is extended
for a further period of: DAYS
Enter the number of days in the box. The maximum is seven days ×
The managing authority has been in contact with the supervisory body and understands that there
are exceptional reasons why the request for a standard authorisation is unlikely to be disposed of
within the timescale of the existing urgent authorisation.
It is essential for the existing deprivation of liberty to continue until the request for a standard
authorisation is disposed of.
PART C — REASONS FOR THE REQUEST
Complete BOTH C1 AND C2.
C1 The exceptional reasons why it has not yet been possible to make a decision on our request for a
standard authorisation are that:
C2 It is essential that the person continues to be deprived of liberty because:
PART D — PROVIDING NOTICE OF THE REQUEST
The managing authority has either given the person who is being deprived of their liberty, and any
section 39A IMCA acting for them, notice that they have made this request or will now do so as
soon as is practicable.
Signed
(on behalf of the managing authority)
Dated
Signature
Print name
Position
Date
GFMA-Liberty Form 2.indd 2 19/2/09 13:19:34
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signature
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