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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 30
IMCA REFERRAL FORM
PART A — BASIC INFORMATION
Full name of the person being deprived of,
or being assessed to be deprived of, their liberty
Name and address of the hospital or care
home where the person is being deprived of,
or being assessed to be deprived of, their
liberty
Person to contact at the hospital or care home
Name and address of the managing authority
responsible for the hospital or care home
Name of the supervisory body instructing the
IMCA
Contact / person to receive IMCA submissions
at the supervisory body
IMCA service to which this referral is being
made
Name
Name
Address
Name
Telephone
Email
Name
Address
Name
Name
Address
Telehone
Email
Name
Address
CASE
NUMBER
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PART B - TYPE OF IMCA INSTRUCTION
Note: 39A, 39C and 39D are the relevant sections of the Mental Capacity Act 2005.
Place a cross in ONE box as appropriate Ø
B1 39 A – an urgent deprivation of liberty authorisation has been given, or a request for a
standard deprivation of liberty authorisation has been made, in respect of a person and
the managing authority of the relevant hospital or care home is satis ed that there is
nobody, other than people engaged in providing care or treatment for the person in a
professional capacity or for remuneration, whom it would be appropriate to consult in
determining what would be in the person’s best interests.
B2 39 A – a supervisory body has appointed an assessor to determine whether or not there
is an unauthorised deprivation of liberty in respect of a person and the managing authority
of the relevant hospital or care home is satis ed that there is nobody, other than people
engaged in providing care or treatment for the person in a professional capacity or for
remuneration, whom it would be appropriate to consult in determining what would be in
the person’s best interests.
B3 39 C – a person deprived of their liberty is without a relevant person’s representative.
B4 39 D – a person deprived of their liberty who has an unpaid relevant person’s
representative has requested the support of an advocate.
B5 39D – an unpaid relevant person’s representative of a person deprived of their liberty
has requested the support of an advocate.
B6 39 D – the supervisory body believes that the person deprived of their liberty will bene t
from the support of an advocate.
B7 39 D - the supervisory body believes that the unpaid relevant person’s representative will
bene t from the support of an advocate.
B8 39 D - the supervisory body believes that the person deprived of their liberty and their
unpaid relevant person’s representative will both bene t from the support of an advocate.
PART C – IN THE CASE OF A 39C IMCA
Name of previous relevant person’s
representative (where appropriate)
Name
Address
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Anticipated duration of 39C IMCA role
Name of next relevant person’s representative
(if known)
PART D – CONTACT DETAILS OF ASSESSORS
Mental health assessor
Best interests assessor
PART E
A 39A IMCA IS ENTITLED TO THE FOLLOWING INFORMATION (where available)
Enter cross to con rm that the document is appended Ø
Copy of urgent authorisation (Form 1)
Record that an urgent authorisation has / has not been extended
(Form 1, where applicable)
Copy of standard authorisation (Form 12)
Notice from the supervisory body that it appears to a best interests assessor that there is an
unauthorised deprivation of liberty (Form 16)
Copy of age assessment (Form 5)
Copy of mental health assessment (Form 6)
Copy of mental capacity assessment (Form 7)
Telephone
Email
Name
Address
Telephone
Email
Name
Telephone
Email
Name
Telephone
Email
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Copy of no refusals assessment (Form 8)
Copy of eligibility assessment (Form 9)
Copy of best interests assessment (Form 10)
PART F
INFORMATION THAT MAY BE HELPFUL TO 39C AND 39D IMCAS
A supervisory body should consider attaching the following documents if it believes they will assist the work
of a 39C or 39D IMCA
Enter cross to con rm that the document is appended Ø
Copy of standard authorisation (Form 12)
Copy of age assessment (Form 5)
Copy of mental health assessment (Form 6)
Copy of mental capacity assessment (Form 7)
Copy of no refusals assessment (Form 8)
Copy of eligibility assessment (Form 9)
Copy of best interests assessment (Form 10)
PART G
OTHER INFORMATION THAT MAY BE HELPFUL TO IMCAS
Also appended to this referral request are the following (where available) because the supervisory body
considers they will assist the work of a 39A, 39C or 39D IMCA
Enter cross to con rm that the document is appended Ø
Copy of relevant care plan
Copy of other relevant document(s)
PLEASE SPECIFY
Signed
(on behalf of the supervisory body)
Dated
Signature
Print name
Position
Date
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