Referral Form: Health & Social Care Complaints Advocacy

Which Local Authority is this for *

LancashireTrafford (Health Complaints Only)

Full Name

Date of birth *

Day

Month

Year

Permanent Address

City

Postcode

Current location if different from permanent address: (including ward)

Telephone Number *

Mobile Phone Number

Email Address *

please specify here

How does the person communicate

EnglishOther spoken language, please specify:British Sign LanguageWords/pictures/MakatonGestures/expressions/vocalisationsNot listed, please specify:No obvious means of communication

please specify here

Have you or any of your family served in the armed forces?

YesNo

Are you making the complaint on behalf of someone?

Name

Relationship

Has their consent been obtained, where possible?

YesNo

Which organisation are you making a complaint regarding:

NHSSocial Care

Who is the complaint about?

What are the names of any staff involved?

Outline of the issue:

When did the treatment/incident occur?

Do you have any upcoming resolution meetings?

What outcome are you hoping to achieve?

Any further information relevant to the complaint:

Does the person have capacity to consent to the referral?

YesNo

If yes, has consent been obtained? *

YesNo

Signature *

If you are referring on behalf of someone else, please provide your details below:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email Address

Phone

Signature *

Which Local Authority is this for *

Disability or impairment:

Gender

Sexual Orientation

How does the person communicate

Ethnic Origin

Religion or belief:

Have you or any of your family served in the armed forces?

Has their consent been obtained, where possible?

Which organisation are you making a complaint regarding:

Does the person have capacity to consent to the referral?

If yes, has consent been obtained? *