DoLS standard - staff

Request for standard authorisation and an urgent authorisation
1. Note: The referrer will receive a copy of this form as an email which you should retain.
2. Is the Managing Authority a hospital?*
  
  Yes
  
  No
3. Which ward is the person in?
4. Personal details
5. Details of the person being deprived of their liberty
6. (Note: It is essential that the full legal name is spelled correctly. Please call 01895 556633 to double check if you are not sure)
7. First name*
8. Last name*
9. Date of birth
10. Estimated age
11. Gender*
  
  Male
  
  Female
12. Relevant medical history (including diagnosis of mental disorder if known)*
13. Sensory loss
  
  Hearing
  
  Sight
  
  Dual
14. Communication requirements?
15. Name of the care home or hospital requesting this authorisation*
16. Street name*
17. Town*
18. Postcode*
19. Contact number*
20. Is the person subject to some element of the mental health act (1983)?*
  
  Yes
  
  No
21. Please describe further eg application/order/direction, community treatment order guardianship