Complaints and Feedback Form

Name

Phone

Email

Preferred contact method

Complaint on Behalf of Another Person

Complete this section only if you are making this complaint or providing feedback on behalf of someone else. If this does not apply, leave this section blank

Your name

Your relationship to the person

Does the person know you are making this complaint on their behalf

YesNoNot applicable

Does the person consent to this complaint or feedback being made

YesNoNot applicable

Subject of Complaint or Feedback

Name of person or service

Contact details (if known)

Details of Complaint or Feedback

Describe your complaint or feedback in detail. Include what happened, where and when it occurred, and who was involved. *

Did you report this to anyone else? Why, When, Why

Supporting Information

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Please attach copies of any documentation that may assist the investigation (e.g. letters, emails, photographs).

Outcomes Sought

What outcome are you hoping for? For example: an apology, a change in practice, or an explanation of what occurred *