Complaints Referral Form

Scroll down to fill out our complaints form.

Complaints Referral Form

Completing the Referral Form – useful information

When you are filling out the form below please provide as much detail as possible as this will allow us to assess your referral as quickly as possible.
In the form the fields with an * (asterisk) are compulsory, this means you need to complete them before you can submit the form to us.
We understand that you may have questions before you wish to submit a complaint. We have provided answers to the most Frequently Asked Questions here. We provide a free, independent, and impartial service.
The term relevant authorities covers many bodies such as schools, health care providers and anyone else providing a function of government. If you are unsure if your complaint is about a relevant authority, please feel free to contact us.
We will be unable to help you if you are already being helped by another organisation.
In submitting this referral you are consenting to the processing of this information in relation to privacy notice and data protection policy, information, disposal and retention policy.

Tell us who you are

Personal Details

This field is hidden when viewing the form

Form Type

Name(Required)

Address(Required)

Postcode(Required)

Contact Number(Required)

Can we leave a message?

Yes

No

Email address(Required)

Our office hours are 9am to 5pm Monday to Friday. What would be the best time for us to contact you?(Required)

Please state how you heard about NICCY

Complaint

Please give the name or names of the child/children you wish to make a complaint on behalf of

Please give the date(s) of birth of the child/children you wish to make a complaint on behalf of

What is your relationship to the child or children concerned e.g. parent, guardian, teacher, social worker etc.

Has the child expressed their views on the complaint to you? If so please record them here

Which organisation do you wish to complain about? E.g. school, health care provider, Trust etc

Who have you dealt with at the organisation in relation to the complaint?

Please outline your complaint and what action you have taken to try to resolve the situation

Did you ask anyone to deal with your complaint? If so what happened?

Why do you believe the organisation’s actions are unfair to the child concerned?

What effect have the actions of the organisation had on the child and on you?

What do you think should be done?

Have you made this complaint to any other organisation or have you taken any advice from anyone else?

Have you taken any legal action?

Please provide any further information which you believe is relevant

Consent for Summary Publication(Required)

We publish anonymised summarises of our casework outcomes. Do you provide your consent to publish an anonymised summary of your complaint?

Yes

No

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Personal Details

This field is hidden when viewing the form

Form Type

Name(Required)

Address(Required)

Postcode(Required)

Date of Birth

Contact Number(Required)

Can we leave a message?

Yes

No

Our office hours are 9am to 5pm Monday to Friday. What would be the best time for us to contact you?(Required)

Email address (required - for contact purposes)(Required)

Please state how you heard about NICCY

Complaint

Which organisation do you wish to complain about? E.g. school, health care provider, Health Trust etc

Have you contacted the organisation in relation to the complaint? Who have you contacted?

Please outline your complaint and any action you have taken?

Why do you think the organisation’s actions are unfair to you?

What effect has this had on you?

What do you think should be done?

Have you made this complaint to anyone else or received advice from anyone else?

Have you taken any legal action?

Is there anything else which you believe is relevant?

Consent for Summary Publication(Required)

We publish anonymised summarises of our casework outcomes. Do you provide your consent to publish an anonymised summary of your complaint?

Yes

No

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Complaints Referral Form