DEPRIVATION OF LIBERTY SAFEGUARDS FORM 1
REQUEST FOR STANDARD AUTHORISATION AND URGENT AUTHORISATION
This form has been compiled in an effort to minimise duplication in completing the DOH
form 4 (Request for a Standard Authorisation) and where required, form 1 (Urgent
Authorisation). This form can be completed instead of forms 1 and 4 and has been adapted
from the new ADASS forms.
If the person’s ordinary residence is within the Dorset County Council area, please
forward to: mcateam@dorsetcc.gov.uk or fax with a header to 01305 224325 for the
attention of the MCA Team. If you need advice in completing this form and whether a
DOLS is needed, please call us on 01305 225650.
If the person’s ordinary residence is within the Bournemouth area, please forward to:
dols@bournemouth.gov.uk or fax 01202 458931, telephone 01202 451657/458823.
For Poole ordinary Residence, please forward to: r.kwong@poole.gov.uk and
deprivationofliberty@poole.gov.uk and telephone 01202 633851.
If the person is self funding, their ordinary residence is where the care home/hospital is
located and the local authority within that area is responsible for the DoLS process.
Please note Deprivation of Liberty Safeguards only applies to people that lack capacity so
by completing this form you are agreeing that this person lacks capacity to make a decision
about where they are staying.
I confirm that the person has an impairment of, or a disturbance in the functioning
of, the mind or brain. This is due or appears to be due to:
On the date below and in relation to the decision, the person was able to:
1. Understand the information relevant to the decision (including the reasonably
foreseeable consequences of deciding one way or another, or of failing to make
the decision).
Select
2. Retain the information long enough to make a decision.
Select
(The fact that a person is able to retain the information for a short period only
does not prevent them from being regarded as able to make the decision).
3. Use or weigh the information to make a decision (degree of awareness and insight,
evidence of reasoning processes).
Select
4. Communicate the decision (to produce a response, not necessarily verbal that
indicates choice, in any way recognised by the assessor).
Select
Failure on any one point above means the person lacks capacity at this time to make the
decision outlined above.(If this is the case then a Best Interests decision must now be
made using the statutory checklist (Section 4 MCA 2005).
The person HAS capacity to make the decision required of them
Record this in the persons notes and review regularly. Deprivation of Liberty Safeguards is
not applicable in this situation.
The person LACKS capacity to make the decision required of them.
Assessor:
Signed:
Position:
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 1 of 6
Date:
Please tick if any of the following are applicable:
Person Objecting
Other Person objecting
Unbefriended (i.e. no family or friends)
High Level of Restriction/restraint
Out of County
AN URGENT AUTHORISATION including REQUEST FOR STANDARD
AUTHORISATION (giving yourself 7 days authority to detain person
A REQUEST FOR STANDARD AUTHORISATION only (to be completed within 21
days, (complete all sections except K)
The DoLS Acid test is: “is the person who is lacking capacity under continuous
supervision and control and are they free to leave?” If the answer is yes and no,
they are likely to be deprived of their liberty.
Full name of person being deprived of liberty:
Date of Birth
Sex : Select
Relevant Medical History
Sensory Loss
Communication Requirements
Date admitted to hospital / Care Home
Reference if any
Name and address of the care home or hospital
requesting this authorisation
Telephone Number
Person to contact at the
care home or hospital
Name
Telephone
Email
Ward (if appropriate)
Present address of the person, (if different to above)
Telephone Number
Name of the Supervisory Body where this form is being sent
Select
How the care is funded (please cross):
Local Authority please specify
NHS
Local Authority and NHS (jointly funded)
Self funded by person
Funded through insurance or other
A. REQUEST FOR STANDARD AUTHORISATION
THE DATE FROM WHICH THE STANDARD AUTHORISATION IS REQUIRED:
If standard only – within 21 days
If an urgent authorisation – within 7 days
In exceptional circumstances, if you need to request an extension of the urgent
authorisation for a further 7 days complete form 1A or phone the DoLS office.
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 2 of 6
PURPOSE OF THE STANDARD AUTHORISATION
Note: there is a legal requirement that the giving of a Mental Capacity Act 2005 deprivation of liberty
safeguards authorisation must be for the purpose of giving care or treatment to the person to whom the
authorisation relates. The entry below should therefore identify the care and/or treatment that constitute the
purpose for which the authorisation is given. It should be borne in mind, however, that the deprivation of
liberty authorisation does not itself authorise the care or treatment concerned, the giving of which is subject to
the wider provisions of the Mental Capacity Act 2005.
The purpose of the urgent authorisation (where applicable) and / or the requested standard authorisation is to
enable the person to be given the following care and / or treatment in this hospital or care home.






Please describe the care and/or treatment this person is receiving 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.
Please give details if they or their family are objecting to the placement and or
attempting to leave/remove them.
Explain why the person is not free to leave and why they are under continuous or
complete supervision and control.
Describe the restrictions you have put in place which are necessary to ensure the
person receives care and treatment. (It will be helpful if you can describe why less
restrictive options are not possible including risks of harm to the person.)
Indicate the frequency of the restrictions you have put in place.
B. INFORMATION ABOUT INTERESTED PERSONS AND OTHERS TO CONSULT
Family member or friend
Anyone named by the person
as someone to be consulted
about their welfare
Anyone engaged in caring for
the person or interested in
their welfare
Any donee of a Lasting Power
of Attorney for Health and
Welfare granted by the person
Any Deputy for Health and
Welfare appointed for the
person by the Court of
Name
Address
Telephone
Relationship
Name
Address
Telephone
Relationship
Name
Address
Telephone
Relationship
Name
Address
Telephone
Relationship
Name
Address
Telephone
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 3 of 6
Protection
Relationship
Any IMCA instructed in
accordance with sections 37
to 39D of the Mental Capacity
Act 2005
Name
Address
Telephone
Any previous/current relationship
C. WHETHER IT IS NECESSARY FOR AN INDEPENDENT MENTAL CAPACITY
ADVOCATE (IMCA) TO BE INSTRUCTED
Place a cross in EITHER box below
Apart from professionals and other people who are paid to provide care or treatment,
this person has no one whom it is appropriate to consult about what is in their best
interests
There is someone whom it is appropriate to consult about what is in the person’s best
interests who is neither a professional nor is being paid to provide care or treatment
D. WHETHER THERE IS A VALID AND APPLICABLE ADVANCE DECISION
Place a cross in one box below
The person has made an Advance Decision that may be valid and applicable to
some or all of the treatment
The Managing Authority is not aware that the person has made an Advance Decision
that may be valid and applicable to some or all of the treatment
The proposed deprivation of liberty is not for the purpose of giving treatment
E. THE PERSON IS SUBJECT TO SOME ELEMENT OF THE MENTAL HEALTH ACT
(1983)
Yes
No
If Yes please describe further
F. OTHER RELEVANT INFORMATION
Names and contact numbers of regular visitors not detailed elsewhere on this form:
Any other relevant information including safeguarding issues:
Please indicate when would be the best time to see the person:
G. PLEASE NOW SIGN AND DATE THIS FORM BELOW
Signature
Print Name
Date
Time
Position
I HAVE INFORMED ANY INTERESTED PERSONS OF THE REQUEST FOR A DoLS
AUTHORISATION (Please sign to confirm)
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 4 of 6
H. RACIAL, ETHNIC OR NATIONAL ORIGIN
Place a cross in one box only
White
British
Irish
White and Black Caribbean
Any other White background (to include Travellers of Irish heritage and Gypsy/Roma)
Mixed OR Mixed British
White and Black African
White and Asian
Any other mixed background
Asian OR Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
Black OR Black British
Caribbean
African
Any other Black background
Other ethnic groups
Chinese
Any other ethnic group
Not stated (to include cases in which the person has refused to divulge their ethnic origin or
where their ethnic origin is not yet known)
I THE PERSON’S SEXUAL ORIENTATION
Place a cross in one box only
Heterosexual
Other
Lesbian or Gay
Prefer not to say
Bisexual
Not Known
J. DISABILITY THAT IS CAUSING THEIR CURRENT INCAPACITY
Place a cross in EACH of the boxes below that apply
Physical disability, frailty and/or sensory impairment
Please identify which of the following apply:
Physical disability, frailty and/or temporary illness
Hearing impairment
Visual Impairment
Dual sensory loss
Mental Health
Please also place a cross in this box if the Mental Health condition is dementia
Learning disability
K. ONLY COMPLETE THIS SECTION IF YOU NEED TO GRANT AN URGENT
AUTHORISATION BECAUSE IT APPEARS TO YOU THAT THE DEPRIVATION OF
LIBERTY IS ALREADY OCCURING AND ALL THESE CONDITIONS ARE MET
URGENT AUTHORISATION
Place a cross in EACH box to confirm that the person appears to meet the particular
condition
The person is aged 18 or over
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 5 of 6
The person is suffering from a mental disorder
The person is being accommodated here for the purpose of being given care or
treatment. Please describe further in section A
The person lacks capacity to make their own decision about whether to be
accommodated here for care or treatment
The person has not, as far as the Managing Authority is aware, made a valid advance
decision that prevents them from being given any proposed treatment
Accommodating the person here, and giving them the proposed care or treatment,
does not, as far as the Managing Authority is aware, conflict with a valid decision
made by a donee of a Lasting Power of Attorney or Deputy for Health and Welfare
appointed by the Court of Protection under the Mental Capacity Act 2005
It is in the person’s best interests to be accommodated here to receive care or
treatment, even though they will be deprived of their liberty
Depriving the person of liberty is necessary to prevent harm to them, and a
proportionate response to the harm they are likely to suffer otherwise
The person concerned is not, as far as the managing authority is aware, subject to an
application or order under the Mental Health Act 1983 or, if they are, that order or
application does not prevent an urgent authorisation being given
The need for the person to be deprived of their liberty here is so urgent that it is
appropriate for that deprivation to begin immediately
AN URGENT AUTHORISATION IS NOW GRANTED
This urgent authorisation comes into force immediately.
It is to be in force for a period of:
days
The maximum period allowed is seven days.
This urgent authorisation will expire at the end of the day on:
Signed
Position
Print name
Date
Time
ACTION NOW NECESSARY:
Due to statutory time limits please forward this form by email or fax WITHOUT DELAY and
MARKED URGENT to the appropriate local Authority/Council.
NB: If making a request for a standard authorisation only, the supervisory body will have 21 calendar days from when this form is
received to complete the necessary assessments. If an urgent authorisation has been granted then the supervisory body must complete
the necessary assessments within the time period that the urgent authority is in force i.e. a maximum of 7 days. However an urgent
authority can be extended in exceptional circumstances where it has not been possible to complete the necessary assessments in time.
The supervisory body should ensure that each assessor, and any instructed IMCA, receives a copy of this form as soon as possible.
Once a DoLS is in place if the person goes home or moves or the DoLS is no longer required, the appropriate DOLS Team must be
informed ASAP. Also, if a person dies whilst on a DoLS, the Coroner must be informed prior to a death certificate being issued.
Name:
DoB:
Managing Authority:
DOLS Form 1, Page 6 of 6