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Derivation of liberty safeguards form 2
Derivation of liberty safeguards form 2
Last Modified January 15, 2024
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Request for a further standard authorisation
Full name of person being deprived of their liberty
Gender
Date of birth (or estimated age if unknown)
Estimated age
GP details
Name and address of managing authority (care home or hospital) requesting this authorisation
Next Page
Person to contact at the care home or hospital,
Include ward details if appropriate
Name
First name
Last name
Telephone
Email
Ward (if appropriate)
The purpose of the authorisation is to enable the following care and/or treatment to be given
• Please describe the care and / or treatment this person is receiving or will receive day-to-day and attach a relevant care plan. • Please give as much detail as possible about the type of care the person needs, including personal care, mobility, medication, support with behavioural issues, types of choice the person has and any medical treatment they receive.
The date from which the standard authorisation is sought:
Other relevant information
Please include details of any changes previously given in Form 1 e.g. in the care plan, medical information, person’s behaviour or visitors.
Name of person submitting this form
First name
Last name
Date
Have you informed any interested persons of the request for a further standard authorisation
Yes
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Submit
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