Raise a Concern Form

CHUMS take your concerns seriously. Please use this form to let us know about any safeguarding issues, concerns about care, or service-related feedback.
If this is an emergency, please contact emergency services immediately.

Contact your GP
Call 111 option 2 or attend A&E for a crisis assessment

Your Details (optional for anonymity)
Full Name

Your Email

Your Phone

Details of Concern
Type of Concern (Required)

Please describe your concern in detail (Include as much information as possible, such as dates, names, and locations)

Who is Involved? (optional)
Is this about someone else? (Select one)
YesNo

If yes, please provide their details (Optional - only include details you're comfortable sharing)
Name of Other Person

Age or Date of Birth of Other Person

Relationship to You

Supporting Information
Do you have any evidence or documents you'd like to share? (e.g., photos, emails)

Privacy and Follow-Up
Would you like us to contact you about this concern? (Required)
Yes, I’d like to be contacted.No, I’d prefer to remain anonymous and not be contacted.

If yes, how should we contact you? (please Selectan Option)
Phone – Call / TextEmail

Consent
I understand that by submitting this form, my concern will be reviewed by the Safeguarding Lead and Operations Director. They will use your preferred method of contact to contact you. I consent to the information provided being used for this purpose.