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Deprivation of Liberty Safeguards Form 1a

Request by a Managing Authority for an extension to the urgent authorisation.

Managing Authority
1. Are you submitting this form on behalf of a care home or hospital?*
  
  Hospital
  
  Care Home
2. 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*
3. Supervisory Body
  1. Supervisory body name*
    
    Powys County Council
    
    Powys Teaching Health Board
  2. Supervisory body address*
4. Care Co-Ordinator/Care Manager
  1. Details of the Care Co-Ordinator/Care Manager
    Key worker details as well as funding authority care co-ordinator i.e Social Worker, Nurse, Care Manager