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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 20
NOTICE THAT A REVIEW IS TO BE CARRIED OUT
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 relevant hospital or
care home
Name and address of the supervisory body
Person to contact at the supervisory body
PART B — GIVING NOTICE OF THE REQUEST AND REVIEW
Place a cross in EITHER box B1 OR box B2 Ø
B1 The supervisory body has itself decided to carry out a review of the standard
authorisation that relates to the person.
B2 The supervisory body has received a request to carry out a review of the standard
authorisation that relates to the person.
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
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If a request for a review has been received (B2), now also complete B3 and B4 by placing crosses in
the relevant boxes.
B3 The person who is the subject of the standard authorisation
Their representative
The managing authority
B4 The standard authorisation is presently suspended and therefore no review can
be requested or carried out while that remains the case.
This standard authorisation is not presently suspended.
Note: no review may be requested while a standard authorisation is suspended. If a review has already
been requested, or is being carried out, no steps may be taken in connection with that review while the
authorisation remains suspended.
If you have received a copy of this notice, it is because the supervisory body is required to give notice of the
review to the following persons:
(a) the person who is the subject of the standard authorisation
(b) the person’s representative
(c) the managing authority of the hospital or care home.
This notice must be given before the review starts or, if that is not practicable, as soon as practicable after it
has begun.
Signed
(on behalf of the supervisory body)
Dated
Signature
Print name
Position
Date
The review was
requested by:
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signature
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