Deprivation of Liberty Safeguards Form 1

Managing Authority's Request for Standard Authorisation and Managing Authority's Urgent Authorisation

Managing Authority
1. Are you submitting this form on behalf of a care home or hospital?*
  
  Hospital
  
  Care Home
2. Are you granting an urgent authorisation?*
  
  Yes
  You will be able to deprive the person of their liberty for up to 7 days
  
  No
  You will be able to deprive the person of their liberty for up to 28 days
3. How is the care and treatment being funded?
  1. Funding Authority*
    
    Powys County Council
    
    Powys Teaching Health Board
    
    Self/Private Funded
    
    Please select all that apply
  2. Has another local authority been involved prior to admission?
    
    Yes
    
    No
    
    Unknown
  4. Further information
    If you have any further information on how the treatment will be funded, please include it here
4. Details of care home or hospital (Managing Authority)
  1. Full name of person submitting this form
    
    Title*
    
    First name*
    
    Surname*
  2. Address
    
    Address lookup
    
    Postcode*
    
    Address
    
    Address*
    
    Ward (if appropriate)
  3. Contact details
    
    Email*
    Please provide the email that should be used for any correspondence relating to this Deprivation of Liberty
    
    Please confirm your email address*
    
    Phone number*