Feedback & Complaints Form

Type *

I am providing feedbackI am making a complaint

Who is completing this form? *

ClientClient Representative

Client Details

First Name

Last Name

Contact Number

Email

I am making this feedback or complaint anonymously
* Please note that if you are making a complaint anonymously, we may be unable to respond to your complaint and let you know what is happening.

Would you like someone to contact you? *

YesNo

Client Representative Details

Please note that by completing this section you are giving Allied Therapy Network authority to liase with this representative on your behalf.

Organisation

First Name

Last Name

Contact Number

Email

Overall, how satisfied were you with the quality of the services provided

Exceeded ExpectationsMet ExpectationsPartially MetDid Not Meet

Would you use our services again if required?

YesNo

What do you like most about our services?

Are there areas in which we could improve?

Other Comments:

Details of Complaint

Date the problem or concern arose *

Who was involved?

Details of problem or concern *Please provide details to help us understand your concerns. You can include what happened, where it happened and who was involved or the decision you are unhappy about.

What outcome(s) are you seeking? Do you want us to change anything in the future? *

How would you like us to let you know about the progress of your complaint?

By phoneBy emailI don't want to be contacted

Please attach any supporting information

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You can also give feedback to the NDIS Commission:

They take feedback or complaints about services that you are not happy with.

You can call them on: 1800 035 544.

Or online here: https://www.ndiscommission.gov.au/participants/complaints.

You can also call the NDIA on 1800 800 110.

You may seek support from family, a friend or an independent advocate when making a complaint. Forfurther information about disability advocacy please visit the NDIS Commission website.