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test form
test form
LA Case Reference
(Required)
Name of Agency
(Required)
Referrer / Point of Contact
Phone
Service Required
(Required)
Stage 2 Complaint
Stage 3 Complaint
STAGE 2 COMPLAINT
Service required
Independent Person
Investigating Officer
Complaint formally accepted on
(Required)
DD slash MM slash YYYY
Stage 1 Complaint / SoC (referrals cannot be accepted without this)
Max. file size: 10 MB.
Report Final Filing date
(Required)
DD slash MM slash YYYY
(55 working days from escalation unless exception)
Any other dates
STAGE 3 COMPLAINTS
Service required
(Required)
Chair
Panel Member
Panel Member
Date of Panel
DD slash MM slash YYYY
Type of Panel
In-person
Online
Special Requests
Risks to IP
Gender
Male
Female
Non-Binary
Transgender
Ethnicity
Second Choice
Third Choice
Age
Care Status
Looked After Child
Care leaver
Other details
Name of complainant
Relationship to Child
Phone
Has the child been notified of the complaint?
Yes
No
No - the complainant is the child
Please provide brief details of the complaint
Action already taken
Outcome sought by complainant
Details of any other professional already appointed for this complaint
Name / Role / Email / Phone
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