Concerns and Complaints Procedure
Appendix 4: Complaints Referral Form

Full name:

Address for correspondence:

Post Code:

Email address:

Contact Telephone Numbers

Mobile: 

Landline: 

Please give the full name of the ACAT member about whom you wish to raise a concern or complaint about:

Please give dates of the beginning and end of therapy and when the event or events occurred:

Please give details of the setting in which the event or events occurred:

Please give a brief description  of the event, or events, which is/are the subject of your complaint.  You may find it helpful to say

1. Something about why you went into therapy

2. A brief description of the circumstances leading to your complaint

3. Details of any records or written evidence

Use a continuation sheet if you need to but please try to limit yourself to 500 words, we will ask for more information when the complaint is investigated.

Have you raised your concerns directly with the member of ACAT concerned?  Please circle as appropriate.

Yes          or        No

If Yes:  please describe what happened as a result:

If No:  please explain briefly, why not:

Has there been any attempt to resolve the matter with the member of ACAT using mediation or other service?  Please circle as appropriate.

Yes    or     No

If Yes:  please attach copies of any previous correspondence relating to this matter with this referral form and briefly detail below:

If No:  please give a brief explanation as to why no attempt to resolve the matter has been made:

To your knowledge, has this matter already been investigated as a complaint or grievance by another organisation?

Yes          or          No

If Yes, please detail and attach any correspondence relating to this matter:

Were there any witnesses to the event / events that are the subject matter of your complaint?   Please circle as appropriate:

Yes          or          No

If Yes, please attach copy of any witness statement.

Please attach any other documents you consider relevant to the complaint.

In order to investigate your concerns or complaint, ACAT requires your permission to send a copy of this referral form to the person being complained about, so they can respond to ACAT.  By signing and dating below, you are giving ACAT that consent. 

ACAT’s Concerns and Complaints Procedure is designed to be transparent to promote respect and fairness to both parties.  In very exceptional circumstances, ACAT may progress a complaint where the complainant requests their identity to be withheld.  If you wish to do this, please discuss the matter with the Complaints and Conduct Officer who made initial contact with you, before you sign this form.

Your name in full:  ................................................................................................................

Signature  ..............................................................................................................................

Date:  .......................................................................................................................................