Complaint Form

We appreciate any suggestions, complaints and comments. To do so, you can speak to your Support Worker or an advocate to complete this form. All information is strictly confidential. We encourage you to make your complaint in writing. Please allow approximately one week for a response.

You may also like to make a complaint directly to the NDIS Quality and Safeguard Commission Phone: 1800 035 544 or Online at: www.ndiscommission.gov.au.

Would you like to place the complaint anonymously?*

YESNO

Your Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Have you lodged a complaint with this business before?*

YESNO

The matter was satisfactorily resolved?*

YESNO

Is there someone (legal representative/support person) that you would like involved in making this complaint?*

YESNO

Details of the representative : *

What happend? *

Where did it happen? *

Who was involved? *

Did anyone witness what happened?*

YESNO

Would they be willing to be contacted?*

YESNO

Any other relevent details? *

Have you spoken to someone about what happened?*

YESNO

What was the outcome?*

What was the reason you were unable to discuss the matter with the other person?*

How would you like the complaint or issue resolved?*

Please attach documents that may be of assistance in handling the complaint:

Signature*

Date*

Date

Complaint Form

Personal Details

Details of the complaint: