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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 12
SUPERVISORY BODY’S DECISION
STANDARD AUTHORISATION
The following standard authorisation has been given
PART A — BASIC INFORMATION
Full name of the person being deprived
of their liberty
Their date of birth (or estimated age if
unknown)
Name and address of the hospital or care home
at which their deprivation of liberty is authorised
Name and address of the managing authority
responsible for this hospital or care home (this is
the person registered under Part 2 of the Care
Standards Act 2000, or the NHS body that
manages the hospital)
Name and address of the supervisory body
granting this standard authorisation
Person to contact at the supervisory body
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
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The present address of the person being
deprived of their liberty
(If, for example, the person is currently living at
home and has not yet been admitted to the
hospital or care home, this will be their home
address. If they are currently living at a different
hospital or care home to the one to which the
request for a standard authorisation relates, this
will be the hospital or care home where they are
at present.)
PART B — THE SUPERVISORY BODY’S DECISION
The supervisory body has received written copies of all the required assessments.
All of the assessments are positive, i.e. each assessment has come to the conclusion that the person meets
the qualifying requirement to which the assessment relates.
This standard authorisation has been given.
PART C — DETAILS OF THE STANDARD AUTHORISATION
C1 DATE ON WHICH THE STANDARD AUTHORISATION COMES INTO FORCE
This standard authorisation is to come into force:
Place a cross in box A or enter the relevant date in row B Ø
A Immediately
B On the following date:
C2 THE PERIOD DURING WHICH THE AUTHORISATION IS TO BE IN FORCE
This standard authorisation is to expire:
Enter the date below Ø
At the end of the day on:
(The period speci ed must not exceed the maximum period speci ed in the best interests
assessment)
As above (already living at the above
hospital or care home)
At a different address which is that given
immediately below:
Address
ddm
m
yyyy
ddm
m
yyyy
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C3 THE PURPOSE FOR WHICH THIS STANDARD AUTHORISATION IS GIVEN
The purpose for which this standard authorisation is given 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 authorising the deprivation of the person’s liberty in the above hospital or care home is so
that they may receive the following care and/or treatment:
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C4 ANY CONDITIONS TO WHICH THIS STANDARD AUTHORISATION IS SUBJECT
Before deciding whether to give the authorisation subject to conditions, the supervisory body had regard
to any recommendations in the best interests assessment concerning such conditions. The supervisory
body should consult the best interests assessor if the best interests assessor’s recommendations are not
being followed and the best interests assessor has indicated in their assessment report that they would
like to be consulted again in that event, since some of the other conclusions that they have reached in their
assessment may be affected.
Place a cross in box A or B Ø
A This standard authorisation IS NOT subject to any conditions
B This standard authorisation IS subject to the following conditions set out
immediately below
If you placed a cross in box B above, list below the conditions to which this standard authorisation is
subject. Be precise about the form of words entered here. Hospital and care home staff must comply with
any conditions that are speci ed. They have no authority to do anything that does not comply with such
conditions.
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2
3
4
5
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PART D — THE SUPERVISORY BODY’S REASONS
The reason(s) why each qualifying requirement is met are as follows:
D1 AGE REQUIREMENT
Place a cross in box A OR B Ø
A The person’s date of birth has been established and s/he is aged 18 or over.
B Although it has not been possible to establish the person’s date of birth, the
supervisory body is satis ed that they are aged 18 or over.
D2 MENTAL HEALTH REQUIREMENT
The person is suffering from mental disorder:
By reference to the mental health assessment, describe the mental disorder(s) from which the
person is suffering.
D3 MENTAL CAPACITY REQUIREMENT
The person lacks capacity to make their own decision about whether they should be accommodated in the
hospital or care home for the purpose of being given the proposed care and/or treatment because of an
impairment of, or a disturbance in the functioning of, the mind or brain. As a consequence:
Place a cross in ONE OR MORE of the boxes below (A–D) Ø
A The person is unable to understand the information relevant to the decision.
B The person is unable to retain the information relevant to the decision.
C The person is unable to use or weigh that information as part of the process
of making the decision.
D The person is unable to communicate their decision (whether by talking, using
sign language or any other means).
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D4 NO REFUSALS REQUIREMENT
The person satis es the no refusals requirement. This is because:
Place a cross in ONE of the boxes below (A or B) Ø
A They have not made an advance decision or a lasting power of attorney under
the Mental Capacity Act 2005 and no deputy has been appointed by the Court of Protection.
B Any advance decision they have made does not prevent them from being given the
treatment proposed, and any decisions made by a donee of a lasting power of attorney
or deputy do not con ict with these proposals for their accommodation, treatment and care.
D5 ELIGIBILITY REQUIREMENT (CARE HOME CASES ONLY)
The person satis es the eligibility requirement because:
Place a cross in the box below to con rm that the statement made there is correct Ø
A Accommodating them in this care home will not con ict with any requirement
imposed on them under any of the following provisions of the Mental Health
Act 1983
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:
(a) a community treatment order
(b) a guardianship application or order
(c) sections 2, 3, 4, 35–38, 44, 45A, 47, 48 or 51.
D6 ELIGIBILITY REQUIREMENT (HOSPITAL CASES ONLY)
The person satis es the eligibility requirement for the following reason:
Place a cross in EITHER Box A OR B Ø
A They are not subject to any relevant provision of the Mental Health Act 1983 and do not
meet the criteria for being detained under section 2 or 3 of the Mental Health Act
1983.
B To the extent that they are relevant, the following statements are all true:
(a) The person is not detained in a hospital under one of the following sections
of the Mental Health Act 1983: sections 2, 3, 4, 35–38, 44, 45A, 47, 48 or 51.
(b) If the person is LIABLE to be detained under one of these sections, the purpose for
which the standard authorisation is requested does not consist wholly or partly of
medical treatment for mental disorder in a hospital.
(c) If the person is LIABLE to be detained under one of these sections, accommodating
them in this hospital will not con ict with a requirement imposed on them in
connection with their liability to detention under the Mental Health Act 1983, for
example as a condition of a leave of absence or conditional discharge from hospital.
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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(d) If the person is on a community treatment order, the purpose for which the
standard authorisation is requested does not consist wholly or partly of medical
treatment for mental disorder in a hospital.
(e) If the person is on a community treatment order, accommodating them
in this hospital will not con ict with a requirement imposed on them under the
community treatment order.
(f) If the person is subject to guardianship, accommodating them in this hospital will
not con ict with a requirement imposed on them by their guardian.
(g) Although the person is subject to guardianship, they either do not object to being
accommodated in this hospital for the purpose of being given some or all of the
medical treatment proposed for their mental disorder, or a donee of a lasting
power of attorney or deputy appointed by the Court of Protection has made a
valid decision to consent to each matter to which they do object.
(h) Although the person meets the statutory criteria for being detained under
section 2 or 3 of the Mental Health Act 1983, they either do not object to being
accommodated in this hospital for the purpose of being given medical treatment for
their mental disorder or to any or all of that proposed treatment, or a donee or deputy
has made a valid decision to consent to each matter to which the person does object.
(i) Although the person meets the statutory criteria for being detained under
section 2 or 3 of the Mental Health Act 1983, or is subject to guardianship, the purpose
for which the standard authorisation is requested does not include treatment for
mental disorder.
D7 BEST INTERESTS REQUIREMENT
The person satis es the best interests requirement for the following reasons:
When completing this section, either copy the reasons given in the best interests assessment or
give a suf cient summary of the reasons to demonstrate to a reader that each of the requirements is
ful lled.
A For the following reasons, the proposed arrangements for the person’s care and/or treatment
amount to depriving them of their liberty in this hospital or care home.
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B For the following reasons, although the proposed arrangements amount to depriving the person of
their liberty they are in the person’s best interests:
C For the following reasons, although the proposed arrangements amount to depriving the person of
their liberty they are necessary in order to prevent harm to the person:
D Although the proposed arrangements amount to depriving the person of their liberty, for the
following reasons they are a proportionate response to the likelihood of the person otherwise
suffering harm and the seriousness of that harm:
PART E — PROVIDING COPIES OF THIS STANDARD AUTHORISATION
As soon as practicable, the supervisory body must give a copy of this standard authorisation to the
following:
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(a) the managing authority of the hospital or care home
(b) the person being deprived of their liberty
(c) any relevant person’s representative appointed for the person
(d) any IMCA instructed for the person under section 39A of the Mental Capacity Act 2005 in relation to their
deprivation of liberty
(e) every person named by the best interests assessor in their report as an interested person whom they
have consulted in carrying out their assessment.
This form is also your notice that any urgent authorisation that has been in force comes to an end when this
standard authorisation comes into force.
PART F — PROVIDING COPIES OF THE ASSESSMENTS
Copies of all the assessments in relation to the above person (including any equivalent assessments) have
been attached to this standard authorisation. They will be sent as soon as practicable to all of the persons
listed in paragraphs (a) to (d) of Part E above.
Unless they also fall within paragraphs (a) to (d) of Part E above, interested persons consulted by the
best interests assessor are entitled to receive a copy of this standard authorisation but not copies of the
assessments.
Signed
(on behalf of the supervisory body)
Dated
NOTE TO THE MANAGING AUTHORITY OF THE HOSPITAL OR CARE HOME
Providing rights information
The managing authority must take such steps as are practicable to ensure that the person understands the
following matters:
(a) the effect of this authorisation
(b) the right to apply to the Court of Protection, asking it to terminate or vary this authorisation
(c) the right to request a review of this authorisation under Part 8 of Schedule A1 to the Mental Capacity Act
2005
(d) the right to have a section 39D IMCA instructed
(e) how to have a section 39D IMCA instructed.
These steps must be taken as soon as is practicable after this authorisation is given, and must include
giving the required information both orally and in writing. The written information given to the person must
also be given to their representative as soon as is practicable after it is given to the person themselves.
If you are informed that a section 39D IMCA has been instructed for the person, this written information must
also be given to that IMCA.
NOTICE TO THE SUPERVISORY BODY
The supervisory body must appoint a person to be the ‘relevant person’s representative’ as soon as
practicable after this standard authorisation is given.
Signature
Print name
Position
Date
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signature
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