Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 6

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 6

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 6
MENTAL HEALTH ASSESSMENT
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 and address 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
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)
Name
Address
Name
Name
Name
As stated on the request for standard
authorisation
As stated immediately below
Address
As stated on the request for standard
authorisation
As stated immediately below
Address
CASE
NUMBER
GFSB-Liberty Form 6.indd 1 19/2/09 13:21:46
2
PART C — RECORD OF THE ASSESSMENT
I have assessed whether the person meets the mental health 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.
Place a cross in EITHER box C1 OR box C2 below Ø
C1 In my opinion, the person IS suffering from mental disorder within the meaning of
the Mental Health Act 1983 (disregarding any exclusion for persons with learning disability).
C2 In my opinion, the person IS NOT suffering from mental disorder within the meaning
of the Mental Health Act 1983
1
(disregarding any exclusion for persons with
learning disability).
If you completed box C1, also complete box C3
C3 In my opinion, the mental disorder from which the person is suffering is (enter diagnosis
or, if this is not established, describe the nature of the person’s disorder, e.g. dementia,
depression).
Give here a brief clinical description of the main symptoms and signs.
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 6.indd 2 19/2/09 13:21:47
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3
I have considered how the person’s mental health is likely to be affected by being deprived of their liberty in
this hospital or care home. In my opinion, their mental health is likely to be affected in the following ways:
Briefl y state here how their mental health is likely to be affected.
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 you have placed a cross in box C2, to indicate that the person is not suffering from mental disorder, then
the person does not meet the mental health 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.
If the person is suffering from mental disorder, you must notify the best interests assessor of your
conclusions as to how the person’s mental health is likely to be affected by their being deprived of their
liberty. You can do that by giving them a copy of this form.
GFSB-Liberty Form 6.indd 3 19/2/09 13:21:47
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 6

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Completed 28 May 2020

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