Concerns and Complaints Procedure
Appendix 4: Complaints Referral Form

Please complete and sign this Complaints Referral Form and return to:
The Chair of the ACAT Ethics Panel
ACAT Office
PO Box 6793
Dorchester DT1 9DL

and
please also email an electronic copy to admin@acat.me.uk

A formal complaint should be lodged within three years of the occurrence of the conduct being complained of.  Concerns and complaints outside this period will be only be considered in exceptional circumstances.

Please also see the ACAT Concerns and Complaints Procedure, Flow Chart, ACAT Codes of Ethics and Practice and associated policies for further information.

Section One:  About You

Full name:

Address for correspondence:

 

 

 

 

 

Post Code:

Email address:

Contact Telephone Numbers

 

Mobile: 

Landline: 

Section Two:  Details of the Complaint

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.

 

 

 

 

 

 

 

 

 

Section Three:  Consent

 

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:  .......................................................................................................................................

 

Please complete and sign this Complaints Referral Form and return to:

1.         The Chair of the ACAT Ethics Panel, ACAT Office, PO Box 6793, Dorchester DT1 9DL
and also
2.         please email an electronic copy to admin@acat.me.uk

Thank you for completing and returning this form.

 

Form approved at ACAT’s AGM 11 July, 2014

ACAT Calendar for July
Sa
Su
Mo
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We
Th
Fr
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77th July 2017
CPD Event: ACAT: CAT, Neuroscience and the Self
8
9
10
11
1212th July 2017
CPD Event: 5 Session CAT Approach - offered by Tees, Esk and Wear Valleys NHS Foundation Trust
13
1414th July 2017
CPD Event: Mapping Mortality in CAT - offered by Catalyse
15
16
17
18
19
20
2121st July 2017
CPD Event: CAT, Neurosciences & the Self - offered by the Somerset Partnership NHS Foundation Trust
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25
2626th July 2017
CAT Skills Training: CAT Skills Case Management - Munro Centre
27
28
29
30
31

Contact Details

ACAT Administration Manager:Susan Van Baars

Administrators:Maria Cross
Alison Marfell

Postal Address:ACAT
PO Box 6793
Dorchester
DT1 9DL
United Kingdom

Phone:+44(0) 1305 263 511

Email:admin@acat.me.uk

Office Hours:Monday to Thursday
9am to 5pm

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