Fillable Dh 124852 GFMA-Liberty Form 4.indd

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Dh 124852 GFMA-Liberty Form 4.indd

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 4
REQUEST FOR A STANDARD AUTHORISATION
Important notes: Regulation 16 of The Mental Capacity (Deprivation of Liberty: Standard
Authorisations, Assessments and Ordinary Residence) Regulations 2008 (SI 2008 No. 1858) contains
requirements about the information to be provided in a request for a standard deprivation of liberty
authorisation.
Regulation 16 states that the information in Part A of this form must be included in every request for
a standard authorisation.
The information in Part B should be provided if it is available to, or could reasonably be obtained by,
the managing authority. The information in Part B does not need to be re-provided in cases where
there is already an existing standard authorisation if that information remains the same as supplied
with the request for the earlier authorisation. However, this does not apply to the information about
an existing authorisation covered in box B14 of this form.
Part C covers further information that might helpfully be provided by the managing authority.
The supervisory body should ensure that each assessor, and any instructed IMCA, receives a copy
of this form as soon as possible.
PART A — INFORMATION THAT MUST BE PROVIDED
A1 Full name of the person who needs to
be deprived of their liberty in this
hospital or care home
A2 Their gender
A3 Their date of birth (or estimated age if
unknown)
The age range within which the person falls
Place a cross in ONE of the boxes below Ø
18–64
65–74
75–84
85+
Name
Male Female
DOB
Est. Age Years
ddm
m
yyyy
CASE
NUMBER
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2
A4 The person’s current location Already in this hospital or care home
(Place a cross in one box, and then Currently at their own private address
enter the current location) D
Currently in another hospital or care home
:
A5
Other (please specify):
Current location (address)
Post Code
Telephone
Name
Address
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
A6 Person to contact at the hospital or care home
A7 THE PURPOSE FOR WHICH THE AUTHORISATION IS REQUESTED
The purpose for which this standard authorisation is requested should be described here.
Note: there is a legal requirement that the giving of a Mental Capacity Act 2005 deprivation of liberty
safeguards authorisation must be for the purpose of giving care or treatment to the person to whom the
authorisation relates. The entry below should therefore identify the care and/or treatment that constitutes
the purpose for which the authorisation is given. It should be borne in mind, however, that the deprivation of
liberty authorisation does not itself authorise the care or treatment concerned, the giving of which is subject
to the wider provisions of the Mental Capacity Act 2005.
The purpose of the requested standard authorisation is to enable the person to be given the following care
and/or treatment in this hospital or care home.
Name
Telephone
Email
Telephone
Postcode
3
A8 THE DATE FROM WHICH THE STANDARD AUTHORISATION IS SOUGHT
The standard authorisation is required to start on this date:
This is because:
Place a cross in ONE of the boxes below Ø
A The existing urgent authorisation expires at that time.
B The existing standard authorisation expires at that time.
C The existing order of the Court of Protection expires at that time.
D We expect to receive the person in this hospital or care home at that time, and it is likely
that we will need to deprive them of their liberty immediately.
E None of the above applies. However, it is likely that the person will need to be deprived
of their liberty and will meet all of the requirements for a standard authorisation at that time.
ddm
m
yyyy
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4
A9 HAS THE MANAGING AUTHORITY GIVEN AN URGENT AUTHORISATION? [Yes] [No]
If yes, please enter the date on which it expires:
PART B – OTHER INFORMATION THAT SHOULD BE PROVIDED IF IT IS AVAILABLE TO, OR COULD
REASONABLY BE OBTAINED BY, THE MANAGING AUTHORITY, UNLESS IT HAS BEEN PREVIOUSLY
PROVIDED IN RESPECT OF AN EXISTING STANDARD AUTHORISATION AND THAT INFORMATION
REMAINS THE SAME
Note: this ‘previously provided’ exemption does not apply to the information about an existing
authorisation covered in box B14 of this form.
B1 RELEVANT MEDICAL INFORMATION
Medical information relating to the person’s health that the managing authority considers to be
relevant to the proposed restrictions to the person’s liberty:
B2 DIAGNOSIS OF THE MENTAL DISORDER
Diagnosis of the mental disorder (within the meaning of the Mental Health Act 1983
1
, but
disregarding any exclusion for persons with learning disability) that the person is suffering from:
B3 RELEVANT CARE PLANS OR NEEDS ASSESSMENTS
The following relevant care plans and/or needs assessments are attached:
B4 RACIAL, ETHNIC OR NATIONAL ORIGIN
The person’s racial, ethnic or national origin
Place a cross in ONE of the boxes below Ø
White
A British
B Irish
C Any other White background (to include Travellers of Irish heritage and Gypsy/Roma)
D White and Black Caribbean
ddm
m
yyyy
1 References in this form to provisions of the Mental Health Act 1983 include provisions of other enactments that have the same effect.
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5
Mixed OR Mixed British
E White and Black African
F White and Asian
G Any other mixed background
Asian OR Asian British
H Indian
J Pakistani
K Bangladeshi
L Any other Asian background
Black OR Black British
M Caribbean
N African
P Any other Black background
Other ethnic groups
R Chinese
S Any other ethnic group
Z Not stated (to include cases in which the person has refused to divulge their ethnic
origin or where their ethnic origin is not yet known)
B5 THE PERSON’S RELIGION OR BELIEF
Place a cross in ONE of the boxes belowØ
None
Christian (Christian includes Church of Wales, Catholic, Protestant and all other
Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion
Not stated
GFMA-Liberty Form 4.indd 5 26/2/09 12:51:16
6
B6 THE PERSON’S SEXUAL ORIENTATION
Place a cross in ONE of the boxes below Ø
Heterosexual
Lesbian or gay
Bisexual
Other
Prefer not to say
Not known
B7
THE PERSON’S DISABILITY – i.e. THE DISABILITY THAT IS CAUSING THEIR CURRENT INCAPACITY
Place a cross (or crosses) as applicable in only one of A OR B OR C
A Place a cross in EACH of the boxes below that apply Ø
Physical disability, frailty and/or sensory impairment
Please identify which of the following apply:
Physical disability, frailty and/or temporary illness
Hearing impairment
Visual Impairment
Dual sensory loss
B Mental Health
Please also place a cross in this box if the Mental Health condition is dementia
C Learning disability
B8 WHETHER THE PERSON HAS A PREFERRED COMMUNICATION OR A PREFERRED FIRST
LANGUAGE
Place a cross in one box
B No Yes
If yes, describe them, e.g. interpreter required (specify language), BSL signer required, etc.
B9 WHY THE PERSON NEEDS TO BE DEPRIVED OF THEIR LIBERTY
In our opinion:
• the person lacks capacity to make their own decision about whether to be accommodated here for
the purpose of being given the proposed care and/or treatment described above
• it is in their best interests to be deprived of their liberty here so that they can be given this care and/
or treatment
• this is necessary in order to prevent harm to them, and it is a proportionate response to the harm
they are likely to suffer if they are not so deprived of liberty, and the seriousness of that harm.
7
Explain here:
(a) the nature of the restrictions on the person’s liberty that lead to the conclusion that they
are, or will be, deprived of their liberty;
(b) why the necessary care and/or treatment cannot be provided in a way that is less
restrictive of the person’s rights and freedom of action;
(c) to the extent that the managing authority is aware, what alternatives to deprivation of
liberty have been considered;
(d) what harm the person is likely to come to if they are not deprived of their liberty in this
hospital or care home.
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8
B10 WHETHER IT IS NECESSARY FOR AN INDEPENDENT MENTAL CAPACITY ADVOCATE (IMCA)
TO BE INSTRUCTED
Place a cross in ONE of the boxes below (A or B) Ø
A 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
interests.
If the person has no relevant person’s representative, or this is a request for a fi rst
standard authorisation, the supervisory body must therefore instruct an IMCA to
support and represent them.
B There is someone whom it is appropriate to consult about what is in this person’s best
interests who is neither a professional nor is being paid to provide care or treatment.
B11 WHETHER THERE IS A VALID AND APPLICABLE ADVANCE DECISION
Place a cross in box A, B or C below Ø
A The person has made an advance decision that may be valid and applicable to
some or all of the treatment.
B The 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 treatment.
C The proposed deprivation of liberty is not for the purpose of giving treatment.
B12 THE PERSON IS SUBJECT TO THE FOLLOWING MENTAL HEALTH ACT 1983 REGIMES
(The hospital treatment, community treatment and guardianship regimes are defi ned in paragraphs 8 to 10
of Part 2 of Schedule 1A to the Mental Capacity Act 2005.)
Place a cross in box A, B or C below if any of those options apply,
otherwise leave the boxes blank Ø
A Hospital treatment regime
B Community treatment regime
C Guardianship regime
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9
B13 INFORMATION ABOUT INTERESTED PERSONS
Please continue on a separate sheet if necessary.
Anyone named by the person as someone to
be consulted about their welfare
Anyone engaged in caring for the person or
interested in their welfare
Any donee of a lasting power of attorney
granted by the person
Any deputy appointed for the person by
the Court of Protection
Any IMCA instructed in accordance with
sections 37 to 39D of the Mental Capacity
Act 2005
B14 IS THERE AN EXISTING STANDARD AUTHORISATION IN RELATION TO THE
DEPRIVATION OF LIBERTY OF THE RELEVANT PERSON Place a cross in box A or B Ø
A There is an existing standard authorisation in relation to the person to be
deprived of liberty.
The authorisation expires on:
Fill in the expiry date above ×
Name
Address
Telephone
Name
Address
Telephone
Name
Address
Telephone
Name
Address
Telephone
Name
Address
Telephone
ddm
m
yyyy
GFMA-Liberty Form 4.indd 9 26/2/09 12:51:16
10
B The managing authority is not aware of any existing standard authorisation
in relation to the person to be deprived of liberty.
PART C – FURTHER INFORMATION
Place a cross in one of these three boxes Ø
C1 The address where the person The address given in box A4 above where
ordinarily resides the person currently is
The person was of no fi xed abode
The following address, at which the person
is ordinarily resident:
C2 The name of the individual who is
considered to be the person most
closely involved in looking after the
person’s welfare.
C3 Name of the PCT or local authority
to whom this form is being sent
(‘the supervisory body’)
C4 How the care is being funded? Local authority
(Place a cross in the relevant PCT
boxes) D
Local authority and PCT jointly
Self-funded by the person, their family,
etc
Funded through insurance, etc
Address
Name
Relationship
Address
Telephone
Name
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11
C5 WHY THIS REQUEST IS BEING MADE
Place a cross in ONE of the boxes below (A–G) Ø
Boxes A–D relate to people who ARE NOT currently subject to a standard authorisation
A PERSON WHO IS ALREADY ACCOMMODATED HERE BUT IS NOT YET BEING
DEPRIVED OF LIBERTY
The person is already accommodated in this hospital or care home. We are not
depriving them of their liberty. However, during the next 28 calendar days, it is likely
that we will need to do so and that they will meet all of the qualifying requirements
for a standard authorisation.
B PERSON WHO IS ALREADY ACCOMMODATED HERE AND BEING DEPRIVED OF
THEIR LIBERTY
The person is already accommodated in this hospital or care home. They already
appear to meet all of the qualifying requirements for a standard authorisation.
An urgent authorisation has been given pending the outcome of the standard
authorisation assessment process.
C PERSON IS NOT YET ACCOMMODATED HERE BUT WILL NEED TO BE
DEPRIVED OF THEIR LIBERTY HERE DURING THE NEXT 28 DAYS
The person is not yet accommodated in this hospital or care home. However,
during the next 28 days it is likely that they will be admitted and that they will
need to be deprived of their liberty here. It is also likely that they will meet all of
the qualifying requirements for a standard authorisation.
D COURT OF PROTECTION ORDER ABOUT TO EXPIRE
The person is already accommodated in this hospital or care home. We are already
depriving them of their liberty and the Court of Protection has authorised this. However,
given the date on which the court’s order is expected to expire, it would be unreasonable
to delay any longer requesting a standard authorisation.
Boxes E–G relate to people who ARE currently subject to a standard authorisation
E EXISTING AUTHORISATION ABOUT TO EXPIRE: NEW STANDARD AUTHORISATION
REQUIRED
There is already a standard authorisation in force that covers the person’s deprivation
of liberty in this hospital or care home. It is reasonable to request a new standard
authorisation to come into force immediately after the expiry of the existing authorisation.
F CHANGE IN THE PLACE WHERE THE PERSON IS DEPRIVED OF LIBERTY
There is already a standard authorisation in force. However, it does not authorise the
person’s deprivation of liberty in this hospital or care home. We therefore require a new
standard authorisation that authorises their deprivation of liberty here.
GFMA-Liberty Form 4.indd 11 26/2/09 12:51:16
12
G A PART 8 REVIEW HAS BEEN REQUESTED OR IS IN PROGRESS
There is already a standard authorisation in force that authorises the person’s
deprivation of liberty in this hospital or care home. A review of this authorisation
under Part 8 of Schedule A1 to the Mental Capacity Act 2005 has either been
requested or is being carried out. Any new standard authorisation that is now given
will be in force after the existing authorisation comes to an end.
C6 ANY OTHER RELEVANT INFORMATION
Signed Signature
(on behalf of the managing authority) Print name
Position
Dated Date
GFMA-Liberty Form 4.indd 12 26/2/09 12:51:16
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Completed 9 February 2020

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