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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 16
UNAUTHORISED DEPRIVATION OF LIBERTY
NOTICE THAT A REQUEST HAS BEEN RECEIVED
For these purposes, there is an unauthorised deprivation of liberty if:
(a) a person is kept in a hospital or care home in circumstances that amount to depriving them of their
liberty; and
(b) their deprivation of liberty has not been authorised by an urgent or standard authorisation under the
Mental Capacity Act 2005, by detention under the Mental Health Act 1983
1
or by the Court of Protection,
and nor is a relevant authorisation presently being sought from that court.
PART A — BASIC INFORMATION
Full name of the relevant person
Their date of birth (or estimated age if
unknown)
Name and address of the relevant hospital
or care home
Name and address of the supervisory
body
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
Telephone
Email
CASE
NUMBER
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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PART B — NOTICE THAT A REQUEST HAS BEEN RECEIVED
The supervisory body has received a request asking it to decide whether or not this person is subject to an
unauthorised deprivation of liberty.
Enter date below Ø
The request was received by the supervisory body on:
The request was made by the following person,
who previously requested the managing authority
to request a standard authorisation in relation to
this person:
Please now complete:
Part C if an assessment is required in relation to the issue; OR
Part D if an assessment is not required.
PART C — DECISION THAT AN ASSESSMENT IS REQUIRED
The supervisory body has decided that an assessment is required.
The supervisory body has appointed the following person to carry out an assessment of whether or not the
relevant person is being kept in this hospital or care home in circumstances that amount to a deprivation of
their liberty.
The person appointed must complete this assessment within seven days of the date on which the
supervisory body received the request, which is given above.
Enter below the name, address, telephone number and Email address of the person appointed:
Name
Address
Telephone
Email
It appears to the supervisory body that the above person would be both eligible and suitable to carry out a
best interests assessment in relation to the person who is the subject of the request to decide whether or
not there is an unauthorised deprivation of liberty (if such an assessment was required in connection with a
request for a standard authorisation).
ddm
m
yyyy
Name
Address
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The supervisory body:
Place a cross in either box A or box B Ø
A is satis eld that, 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. An IMCA is therefore being instructed under section 39A of the Mental
Capacity Act 2005.
B is satis ed that there 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. An IMCA is not therefore being instructed.
PART D — DECISION THAT AN ASSESSMENT IS NOT REQUIRED
The supervisory body has decided that an assessment is not required because it appears to it that:
Place a cross in box D1 or D2, or both Ø
D1 The request is frivolous or vexatious.
D2 (a) The question of whether or not there is an unauthorised deprivation of liberty has
already been decided; AND
(b) Since that decision was made, there has been no change of circumstances that
merits the question being decided again.
PART E — REASONS FOR THE SUPERVISORY BODY’S DECISION
The supervisory body’s reasons for its decision are as follows:
(Give reasons for deciding that, for example, the request is frivolous or vexatious, or that circumstances
have not changed since the question was last decided.)
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Please Use Continuation Sheet
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PART F — GIVING NOTICE OF THE DECISION
If you have been given a copy of this notice, it is because the law requires the supervisory body to give
notice of this decision to:
(a) the person who made the request to the supervisory body, asking it to decide whether there was an
unauthorised deprivation of liberty
(b) the person to whom the request relates
(c) the managing authority of the relevant hospital or care home
(d) any IMCA instructed for the person in (b) under section 39A of the Mental Capacity Act 2005.
Signed
(on behalf of the supervisory body)
Dated
Signature
Print name
Position
Date
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click to sign
signature
click to edit
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