Neta Care Feedback Form

Feedback Form
Our service is committed to providing high quality care and services and meeting your needs.

We value your feedback. Please let us know what we do well and where we can improve our services.

If for some reason, you have a problem with this form, please call our office to speak directly with our staff, who can assist you.

This is a...*
Is this a three-month check-in?
Date completing this form:*

DayMonthYear
Date

Do you grant permission for this information to be used for training purposes?*

YesNo
Do you grant permission for this information to be used for marketing purposes?*

YesNo

Do you want to remain anonymous?*

YesNo
You may choose to remain anonymous. Be advised: If making a complaint, a manager will contact you to confirm receipt, advise you of the outcome of actions taken, and ensure that you are satisfied with the outcome. This will take place within the space of one month from receipt. If you choose to remain anonymous, it will not be possible for the manager to contact you as part of this process.

Your details
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number

Preferred method of contact*
Do you require an interpreter?*

YesNo
Language Preference:

Are you providing feedback on behalf of someone else?*

YesNo

Feedback made on another person's behalf

Please provide the details about the person on whose behalf you are acting.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email Address
example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you a legal representative for the person who received the service? (e.g. parent of a child under 18 years or guardian)

YesNo
If yes, please provide details.
Does the person know you are filling out the feedback form on their behalf?

YesNo
If no, please state the reason why.

Are we able to speak with the person who received the service?

YesNo
If no, please state the reason why.

Other person’s consent for feedback made on their behalf

This question may only be completed with the express permission of the person whose information is being supplied.
I give permission for relevant information to be gathered and provided as required for the purposes of this feedback.*

I consentI do not consent

Feedback details

Please provide details that the feedback concerns.
This feedback is from*
This feedback is about*
Name of the service provider*

Feedback
Please provide details of your main topic of feedback, including what events led to making the feedback, approximate dates and who was involved. *
Have you discussed this with the service provider or another agency?*

YesNo

If yes, with whom, and what was the outcome?
What outcomes would you like as a result of this feedback?*

Privacy notice
Neta Care Holistic Health Services (NCHHS) is committed to protecting your privacy. We collect and handle personal information that you provide on this feedback form for the purpose of investigating and responding.

NCHHS will only use your information in accordance with relevant privacy and other laws. In order for us to provide services to you effectively and efficiently, we may need to share your personal information with others, such as staff who deal with the matters identified in your feedback.

If you choose to remain anonymous, NCHHS may be unable to deliver the full range of services you require.

If you wish to contact NCHHS, who are responsible for managing the personal information that you provide on this form, please call 1300 389 562.

You also have the right to access your information and seek its correction under the Freedom of Information Act 1982. For information about making a Freedom of Information application contact the Compliance Team on 1300 389 562.

Please check the box below to indicate you have read and agree to this privacy notice.*

I have read the above privacy notice and agree that Neta Care Holistic Health Services (NCHHS) may collect and use my personal information for the purpose of investigating and responding to my submitted feedback.

Declaration & submit feedback
Please check the box below to confirm the information you have provided in this feedback submission is true and accurate.*

I declare the information is true and accurate.
Thank you for taking the time to provide feedback about our service.
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