NDIS Complaint Form
Are you submitting the complaint yourself or on behalf of someone else?
Myself
Behalf of someone else
Full Name
First Name
Last Name
NDIS Number
(if available)
Date of Complaint Made
-
Day
-
Month
Year
Date
Is someone assisting you with the complaint?
Yes
No
Fill in this section if you are complaining on behalf of someone else
Name of Person
Their NDIS Number
What is your relationship to that person?
Does the person know you are making this complaint?
Yes
No
Does the person consent to the complaint being made?
Yes
No
Fill in this section if someone is assisting you with the complaint – for example a family member, your nominee or representative.
Name of representative
Organisation
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Numbers
Business Number
Mobile Number
Fax Number
TTY
Email
example@example.com
My preferred contact is:
Business
Mobile
Fax
TTY
Email
What is your complaint about?
Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved or the decision made by the The Innovative Dietitian that you are unhappy about.
Who is your complaint about?
Name of the person, or service about whom you are complaining (the respondent or the person who made the decision)
Name/organisation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Numbers
Home Number
Business Number
Fax Number
Mobile Number
TTY
Email
example@example.com
What is this person’s/organisation’s relationship to you?
What outcomes are you seeking?
Supporting Information
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Please attach copies of any documents that may help us investigate your complaint (for example letters, references, emails). If you cannot do this, please tell us what you think we should obtain.
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Have you made a complaint about this to another agency?
(For example: a disability service or equal opportunity agency, Health Care Complaints Commission, Ombudsman.) If so, please provide details of the agency to which you made your complaint and any outcome. Please also attach copies of any letters you have received from that agency.
Supporting Information
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Choose a file
Cancel
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Please check this box to consent to The Innovative Dietitian providing information to a third party (e.g. a Provider or another jurisdiction) to resolve your issue.
I agree
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