Deprivation of Liberty Safeguards Form 1b

Report of a potential deprivation of liberty by a family member, friend or supporter

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1. Is the person being deprived of their liberty in a care home or hospital?*
  
  Hospital
  
  Care Home
Request to the supervisory body to consider whether or not there is an unauthorised deprivation of liberty in respect of:
1. Full name of the person being deprived of liberty
  1. Title*
  2. First name*
  3. Surname*
2. Is the person's date of birth known?*
  
  Yes
  
  No
3. Date of birth
  
  Day
  
  Month
  
  Year
5. Estimated age
6. Unable to continue
  
  The person must be at least 18 years old
7. Usual address of the person who appears to be deprived of liberty
  1. Address lookup
    
    Postcode*
    
    Address
  2. Address*
8. Date of admission*
  
  Day
  
  Month
  
  Year