Complaint Form

Client Details (skip this section if you wish to remain anonymous)

First Name

Last Name

Date of Birth

NDIS Number (if available)

Phone Number

Email Address

Client Representative Details (if you are completing this form on behalf of someone else)

Name of Representative/Organisation

Address

Street address

City

State

Postcode

Contact Number

Client Name

Client Phone Number

Client Email

What is your relationship to the person you are making this complaint on behalf of?

Does this person know you are making this complaint?

Yes No

Does this person consent to the complaint being made?

Yes No

Complaint Further Details

Date the complaint was lodged *

What person/organisation is this complaint about? *

What is this person's/organisation's relationship to you/your client? *

Your Complaint

Use the space below to tell us about your complaint. Please include as much detail as possible about your complaint or the incident that has occurred. You should include details of what happened and when it happened, the date this occurred, the location, and who was involved. *

Supporting Information

Please attach copies of any documents that you think may help us better understand and investigate your complaint (e.g. letters, photos, emails, etc).

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Outcome

Please explain what you would like to see happen after this complaint has been made. *