Request leave for restricted patients
Complete this form to apply for S17 leave for a restricted patient being treated for mental health issues at your hospital.
MS Word Document, 68KB
This file may not be suitable for users of assistive technology. Request an accessible format.
If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email email@example.com. Please tell us what format you need. It will help us if you say what assistive technology you use.
PDF, 843KB, 20 pages
This form should be filled in by the clinician responsible for the restricted patient’s care.
You should complete it when asking for S17 leave of absence for the patient. You can also use it to report changes in the patient’s circumstances.
The Secretary of State must have an up-to-date report on all previous leave before considering any new requests.
Check the attached guidance if you need more information.
Email the completed form to the relevant Mental Health Casework team as shown below.
|Last name of patient||Casework team||Email to|
|A to Gile||Team firstname.lastname@example.org|
|Gilf to Nicholl||Team email@example.com|
|Nicholm to Z||Team firstname.lastname@example.org|
After the patient has returned, you must fill in a completed leave report.