Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 3

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 3

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 3
SUPERVISORY BODY’S DECISION CONCERNING
REQUEST FOR EXTENSION OF URGENT AUTHORISATION
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
where the person is being deprived of their liberty
Name and address of the PCT or local authority
making this decision (the ‘supervisory body’)
Person to contact at the supervisory body
PART B — THE SUPERVISORY BODY’S DECISION
An urgent authorisation is in force in respect of this person.
The managing authority of the hospital or care home has requested that it is extended for a further period.
Place a cross in EITHER Box B1 OR Box B2 Ø
B1 The extension is granted because it appears to the supervisory body that
ALL of the following three grounds are satisfi ed:
(a) the managing authority has requested a standard authorisation; AND
(b) there are exceptional reasons why it has not yet been possible for that
request to be disposed of; AND
(c) it is essential that the person’s existing deprivation of liberty continues until the request is
disposed of.
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
GFSB-Liberty Form 3.indd 1 19/2/09 13:20:56
2
B2 The request for an extension is refused because it DOES NOT appear to
the supervisory body that ALL of these three grounds are satisfi ed.
PART C — THE SUPERVISORY BODY’S REASONS
Complete EITHER C1 OR C2.
C1 COMPLETE C1 IF THE EXTENSION IS GRANTED
The supervisory body’s reasons are as follows:
1. The managing authority has made the required request for a standard authorisation.
2. The exceptional reasons why it has not yet been possible to dispose of the request for a standard
authorisation are that:
3. It is essential for the existing deprivation of liberty to continue until the request is disposed of
because:
C2 COMPLETE C2 IF THE EXTENSION IS REFUSED
The following ground(s) for granting an extension is/are not satisfi ed:
Place a cross in at least one of the boxes below Ø
A The managing authority has not made the required request for a standard
authorisation
B The reasons why it has not been possible to dispose of their request for a
standard authorisation are not exceptional
C It is not essential for the person’s deprivation of liberty to continue until the
request for a standard authorisation has been disposed of.
D The reasons why the ground(s) indicated above are not satisfi ed are that:
GFSB-Liberty Form 3.indd 2 19/2/09 13:20:56
Please Use Continuation Sheet
Please Use Continuation Sheet
Please Use Continuation Sheet
3
PART D — DETAILS OF ANY EXTENSION GRANTED
This urgent authorisation has been extended:
for a further period of: DAYS
Enter number of days in the box above ×
The period specifi ed must not exceed seven days
Unless the request for a standard authorisation is disposed of before then, this urgent authorisation will
now expire:
at the end of the day on:
Enter new date on which it will expire above ×
PART E — GIVING NOTICE OF THE EXTENSION
The supervisory body will give the managing authority a copy of this form as soon as practicable.
Signed
(on behalf of the supervisory body)
Dated
NOTE TO THE MANAGING AUTHORITY OF THE HOSPITAL OR CARE HOME
Varying the original urgent authorisation
If this notice extends the urgent authorisation, the managing authority should vary the original urgent
authorisation by entering details of the extension granted in Part H of Form 1.
Providing rights information
The managing authority must take all practicable steps to ensure that the person who is deprived of liberty
understands:
(a) the effect of any extension of the urgent authorisation
(b) their right to make an application to the Court of Protection, challenging the urgent authorisation.
These steps must be taken as soon as is practicable after this extension is given. The required information
must be given both orally and in writing.
ddm
m
yyyy
Signature
Print name
Position
Date
GFSB-Liberty Form 3.indd 3 19/2/09 13:20:56
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 3

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Completed 29 May 2020

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