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.
This form should be filled in by the clinician responsible for the restricted patient’s care.
Complete the relevant form depending on which type of S17 leave of absence you are requesting 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.