Complaints / Feedback Form
Instructions:
1. Complete this form 2. Forward with information to our Complaints Manager via email, website or post 3. The Complaint Manager will contact you upon receipt of this form.Note: You can send in the Anonymous Complaints and Feedback form in the stamped self-addressed envelope that you received at intake.
Fill in the details of the person who is making the complaint/ providing feedback.
Name of person
*
Address
*
Phone
*
Email
*
My preferred contact method is
*
If you are making the complaint/feedback on behalf of another person provide the following details.
Your Name:
*
What is your relationship to the person?
*
Does the person know you are making thiscomplaint/providing feedback?
*
Does the person consent to thecomplaint/feedback being made?
*
Who is the person, or the service about whom you are complaining or providing feedback about?
Name
*
Contact Details (if known)
*
What is your Complaint/Feedback about?Provide some details to help us understand your concerns. You should include what happened, where it happened,time it happened and who was involved.
*
Supporting InformationPlease attach copies of any documentation that may help us to investigate your complaint/feedback (for exampleletters, references, emails).
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What outcomes are you seeking because of the complaint/feedback?
*
OFFICE USE ONLY
Complaint received by
Date received
Action taken or required(Include Continuous Improvement, if relevant)
Date action completed
Signature
Submit
Should be Empty: