Client Complaint Form

We provide a high quality service but are always looking to improve. We value any feedback positive or negative and promise to act upon it. Any complaint we receive will be treated seriously and we promise a personal reply . If you are unhappy about any particular aspect of the service you have received please let us know immediately and we will endeavor to find a solution.

As an NDIS provider we are committed to a high standard of service. Having passed stringent criteria and vetting procedures we are obligated to follow a strict set of guidelines.

It terms of any alleged neglect or abuse of a participant, death or alleged assault on a participant we will immediately carry out a full investigation. We have our own guidelines to follow. A full transparent enquiry will take place and the findings will be made available.

This form is to assist you in making a complaint to our organisation.
All persons wishing to make a complaint can speak with the Manager or staff member of choice or choose to complete this form.
All information is strictly confidential.
If you feel unsure about anything or would like help to complete this form, please speak to the Administration Officer.
We encourage you to make your complaint in writing. Please allow a maximum of ten (10) days for a response.

Date

Personal Details:

The information provided will be used to contact you. Only provide the contact details that you wish to be contacted on.

Name: Mr/Mrs/Miss/Ms

Postal Address:

Postcode:

Phone No:

Mobile:

Have you lodged a complaint with our organisation before?

YesNo

If yes, was the matter resolved?

Comments:

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

YesNo

If yes, what is the name of legal representative/support person?

Postal Address:

Phone:

E-Mail:

Details of the complaint

Is the complaint related to:

Employee of the organisation

Volunteer of the organisation

Service Delivery

Facilities

Specific Incident

What happened?

Where did it happen?

When it happened? (Include date if possible)

Who was involved? (List all person involved and witnesses)

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.)

Any other relevant details:

Have you discussed the matter with the person/s involved?

YesNo

If yes, what was the outcome, if any? Please attach a copy (not the original) of your complaint to the respondent and any letter of reply you have received.

If no, is there any reason/s that you cannot do so? Do you need help to do this, e.g. for safety reasons, cultural reasons?

How would you like to see your complaint resolved? What action would you like the
organisation to take to resolve your complaint?

Please attach copies (not the original) of any documents that may help us to handle the
complaint, e.g. if you have letters, emails or faxes or records of conversations you have had with the person/s associated with the complaint.
To help us resolve this matter as fast as we can, please ensure your contact details are kept up to date. If details change, let the organisation know as soon as you can.

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