Feedback and Complaint Form
This form is to assist you in providing feedback making a complaint to our organisation. All information is strictly confidential.If you feel unsure about anything or would like help to complete this form, please speak to the admin person. We welcome your feedback and suggestion and will use what you tell us to review our services. We also encourage our clients and their families to share about your experience with us. Please allow a maximum of ten (10) days for a response.Please attach copies (not the original) of any documents that may help us to handle the complaint.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
E-mail
*
example@example.com
Feedback Type
*
Compliment
Suggestion
Complaint
Feedback
Other
Please provide your feedback or suggestions
Would you like us to contact you about your feedback?
*
Yes
No
Is there someone else (legal representative or support person) that you would like involved in making this complaint?
Yes
No
Fill in this box if you are complaining on behalf of someone else
Name of Person
What is your relationship to that person
Phone Number
Does the person know you are making this complaint?
Yes
No
Does the person consent to the complaint being made?
Yes
No
What is your complaint about? Please provide details so we can understand your concerns including what happened, when, who is involved and any other details
*
Attach any evidence that will help us to assess your complaints
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like us to contact you about your complaint?
*
Yes
No
Did someone witness the incident? Would they be willing to be contacted regarding your complaint? If so, provide the name and contact details. (Inform the witness that they may be contacted by the organisation to discuss the matter.)
How can we help to fix this problem or complaint?
*
Submit
Should be Empty: