Form

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.

Documents

Leave application form for restricted patients

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If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email web.comments@justice.gsi.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Medical leave application form for restricted patients

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 web.comments@justice.gsi.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Amendment to guidance and application form for Section 17 Leave of Absence

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If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email web.comments@justice.gsi.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Details

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.

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 1 mhcsteam1@noms.gsi.gov.uk
Gilf to Nicholl Team 2 mhcsteam2@noms.gsi.gov.uk
Nicholm to Z Team 3 mhcsteam3@noms.gsi.gov.uk

After the patient has returned, you must fill in a completed leave report.

Published 27 February 2011
Last updated 30 August 2017 + full page history
  1. Addition: Medical leave application form for restricted patients
  2. Updated form and guidance
  3. First published.