Contact Form

Customer Details

1. Title Select... Mr Mrs Ms Miss Dr  
2. First Name  
3. Surname  
4. Address 1  
5. Address 2
6. Address 3
7. Town / City  
8. County  
9. Postcode  
10. Contact Telephone  
11. Email Address  
12. Confirm Email Address  
13. Contact Preference EmailLetterTelephone  

1. Type of feedback Select... Compliment Comment Criticism Complaint  
2. 1. Tell us about your compliment, comment, criticism or complaint  
3. 2. Have you previously reported this issue? If so to whom and when? Was any action taken?
4. 3. Can you tell us how we can resolve this situation for you?
5. Are you willing to answer a few questions about your diversity background?
   This information will be used to help us assess whether any groups of people have different levels of satisfaction with the services provided by Sanctuary Group. These questions are voluntary and any information you provide will be stored sensitively and confidentially. The information will only be used to help us improve and monitor our services and will not be shared with other agencies.
   
   Yes - I would like to complete this section. No - Allow me to submit this form without completing this section.

About You

1. Data Protection Act 1998. The details you provide on this form will only be used to help us improve and monitor our services and your information will not be shared with other agencies. The Data Controller is Sanctuary Group.
2. Please complete the boxes below and help us to ensure our services are accessible to everyone.
3. 1. What is your gender? MaleFemaleDecline to state
4. 2. How old are you? Under 1616-2425-4445-6465+Decline to state
5. 3. Do you consider yourself to be disabled or to have a long term health condition? YesNoDecline to state
6. 4. What is your ethnic origin? Select... Asian Bangladeshi Asian British Asian Indian Asian Pakistani Any other Asian Background Black African Black British Black Caribbean Any other Black Background Chinese Any other Ethnic Group Mixed White and Asian Mixed White and Black African Mixed White and Black Caribbean Any other Mixed Background White British White Irish White Other Declined to state
7. 5. What is your religion? Select... No religion Christian (including Church of England, Catholic, Protestant & all other Christian denominations) Buddhist Hindu Jewish Muslim Sikh Other Prefer not to say
8. If none of the above apply, please state your religion here.
9. 6. What is your sexual identity? Gay manGay woman / lesbianHeterosexual / straightBisexualPrefer not to say
10. 7. Is your gender identity the same gender you were assigned at birth? YesNoDecline to state