1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 17
UNAUTHORISED DEPRIVATION OF LIBERTY
ASSESSOR’S REPORT
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
Name, address and profession of the assessor
Full name of the person being assessed
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
Address
Profession
Name
DOB
Est. age Years
Name
Address
Name
Address
Name
Telephone
Email
ddm
m
yyyy
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
GFSB-Liberty Form 17.indd 1 19/2/09 13:22:35
2
PART B — RECORD OF THE ASSESSMENT
I have assessed whether or not the person is being kept in the hospital or care home in circumstances that
amount to a deprivation of their liberty.
In carrying out this assessment, I have taken into account any information given to me, and any
submissions made, by any IMCA instructed for the person under section 39A of the Mental Capacity Act
2005
Place a cross in EITHER box B1 OR box B2 Ø
B1 I have concluded that the person IS being kept in this hospital or care home in
circumstances that amount to a deprivation of their liberty.
B2 I have concluded that the person IS NOT being kept in this hospital or care home
in circumstances that amount to a deprivation of their liberty.
My reasons for concluding that the person is, or is not, being kept in the hospital or care home in
circumstances that amount to a deprivation of their liberty are as follows:
PART C — INFORMATION AS TO WHETHER ANY DETENTION IS AUTHORISED
Only complete Part C of the form if you concluded that the person IS being kept in this hospital or
care home in circumstances that amount to a deprivation of their liberty.
Although not required by the Mental Capacity Act 2005, the following information is provided to the
supervisory body to assist it in deciding whether or not the person’s deprivation of liberty is authorised under
the Mental Capacity Act 2005.
GFSB-Liberty Form 17.indd 2 19/2/09 13:22:35
Please Use Continuation Sheet
3
Place a cross in ONE of the boxes below (C1–C4) Ø
C1 It appears to me that the deprivation of liberty of the person is authorised under
the Mental Capacity Act 2005.
I am satis ed that a Court of Protection order, standard authorisation or urgent
authorisation is in force in relation to the person’s deprivation of liberty, or that a
relevant authorisation is presently being sought from that particular court.
If C1 applies, describe the authority in the box below,
e.g. you might write ‘a standard authorisation given by
A N Other PCT on 1 January 2009 for a period of 12 months’.
C2 It appears to me that the deprivation of liberty of the person is not authorised
under the Mental Capacity Act 2005, and nor has it been authorised under the
Mental Health Act 1983 or by some other authority or court (such as the High Court).
C3 The person’s deprivation of liberty in the hospital is authorised under the Mental
Health Act 1983 or by some other authority or court (such as the High Court).
If C3 applies, describe the authority in the box below, e.g.
the relevant section of the Mental Health Act 1983.
C4 I am unable to say whether or not the person’s deprivation of liberty is authorised
under the Mental Capacity Act 2005, or under some other Act or authority, and
further enquiries by the supervisory body need to be made.
PART D — PROVIDING COPIES OF THIS ASSESSMENT
If you have received a copy of this assessment, it is because the law requires the supervisory body to give
copies of this assessment to:
(a) the person who was the subject of the request to decide whether or not there was an unauthorised
deprivation of liberty
(b) the managing authority of the hospital or care home
(c) any section 39A IMCA.
Signed
Dated
GFSB-Liberty Form 17.indd 3 19/2/09 13:22:35
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome