Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 5

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 5

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 5
AGE ASSESSMENT
An age assessment is required for a standard authorisation. However, there is no need to complete
this form if the best interests assessor states that the person is aged 18 or over on the best interests
assessment form.
Note that an age assessment is not required if the supervisory body has a written copy of an earlier
age assessment, and there is no reason to believe it is not accurate. If you do re-use a previous
assessment then you must complete Form 11.
PART A — WHY THIS FORM IS BEING COMPLETED
Place a cross in one of the boxes below Ø
A1 This form is being completed in relation to a request for a standard
authorisation.
A2 This form is being completed in relation to a review of an existing standard authorisation
under Part 8 of Schedule A1 to the Mental Capacity Act 2005.
PART B — BASIC INFORMATION
Name, address and profession of the assessor
Full name of the person being assessed
Name of the hospital or care home in which the
person is, or may become, deprived of their liberty
Name of the PCT or local authority that
is the supervisory body
Name
Address
Profession
Name
Name
Name
CASE
NUMBER
GFSB-Liberty Form 5.indd 1 16/2/09 11:42:29
2
The present address of the person being assessed
(Place a cross in the relevant box and, where
applicable, state the address)
Address of the hospital or care home in which the
person is, or may become, deprived of their liberty
(Place a cross in the relevant box and, where
applicable, state the address)
PART C — RECORD OF THE ASSESSMENT
I have assessed whether the person meets the age requirement.
In carrying out this assessment, I have taken into account any information given to me, and any
submissions made, by any of the following:
(a) any relevant person’s representative appointed for the person
(b) any IMCA instructed for the person in relation to their deprivation of liberty.
Enter the person’s date of birth in row C1 or place a cross in box C2 or C3 Ø
C1 The person’s date of birth is:
C2 I have not been able to establish the person’s date of birth. However, to the best of
my knowledge and belief s/he will be AGED 18 OR OVER when the requested standard
authorisation comes into force.
C3 I have not been able to establish the person’s date of birth. However, to the best of
my knowledge and belief s/he will be UNDER 18 YEARS OF AGE when the
requested standard authorisation comes into force.
As stated on the request for a standard
authorisation
As stated immediately below
Address
As stated on the request for a standard
authorisation
As stated immediately below
Address
ddm
m
yyyy
GFSB-Liberty Form 5.indd 2 16/2/09 11:42:30
3
PART D — REASONS FOR OPINION
Give here the reasons for your opinion that the person is aged 18 or over, or is under 18 years of
age.
Signed
Dated
WHAT TO DO NOW
It is essential that you give a copy of this assessment to the supervisory body as soon as you have
completed it. This is because the supervisory body may not give a standard authorisation unless and until
it has written copies of all the assessments. If the person will be under 18 years of age when the proposed
standard authorisation would come into force, then they do not meet the age qualifying requirement. As
a result a standard authorisation may not be given and all other on-going assessments should stop. You
should immediately notify the supervisory body, and then provide them with a copy of this assessment as
soon as practicable. You must keep a written record of the assessment.
GFSB-Liberty Form 5.indd 3 16/2/09 11:42:30
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 5

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Completed 28 May 2020

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