Feedback & Complaint Form for WattleCare Services & Wattle and River Home Health
Share your feedback, concerns, or compliments to help us improve our services.
Who Is Submitting This Form
Respondent role
*
Older person receiving services
Family member
Representative / Nominee
Advocate
Other supporter
Would you like to remain anonymous?
*
Yes
No
Your Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Name of older person receiving services (if different)
Type of Feedback
What would you like to provide?
*
Compliment
General feedback
Suggestion for improvement
Concern
Formal complaint
What is your feedback about?
*
Care or service delivery
Staff communication
Staff conduct
Reliability / missed services
Respect / dignity
Choice and decision-making
Safety concern
Billing / administration
Care planning
Complaint handling
Other
Details of Feedback / Complaint
Please describe the issue or feedback
*
When did this occur?
-
Month
-
Day
Year
Date
Where did this occur?
How has this affected you / the older person?
Urgency & Safety
How urgent is this matter?
*
Low
Moderate
High
Urgent / Immediate action required
Does the concern involve immediate risk to health, safety or wellbeing?
*
Yes
No
Unsure
Please provide details
Previous Reporting
Has this issue previously been raised with WattleCare?
*
Yes
No
Who did you speak with?
Were you satisfied with the response?
Yes
Partly
No
Please tell us why
Desired Outcome
What outcome would you like?
*
Explanation
Apology
Service improvement
Staff follow-up
Review of care arrangements
Management contact
Formal investigation
Other
Additional comments regarding your preferred outcome
Accessibility & Communication
How would you prefer WattleCare to contact you?
*
Phone
Email
Letter
No follow-up required
Other
Do you require any communication support?
Interpreter
Written communication
Representative contact
Large print
No support required
Other
Rights & Confirmation
Confirmation of understanding
*
I understand my feedback will be reviewed fairly and respectfully
I understand making a complaint will not affect care or services
I understand I may contact the Aged Care Quality and Safety Commission if I am dissatisfied with WattleCare’s response
I feel comfortable raising concerns with WRHH
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Submit Feedback
Should be Empty: