Feedback & 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 addressStreet address line 2

City

State

Postcode

Country

Contact Number

Client Name

Client Phone Number

Client Email

What type of Feedback would you like to submit? *

ComplimentSuggestionComplaintOverall Feedback

If Compliment, Suggestion or Overall Feedback

How happy are you with your supports at Movement Five?

Very HappyMostly HappySomewhat HappyNot Happy

What activities do you enjoy the most?

GymGroup ActivitiesOne-on-one activitiesCampingMusic & showsRespiteMeal PreparationLife SkillsOther

Are there any of the above activities you would like to try?

Have you noticed any changes in your skills and/or daily life since you started with Movement Five?

Yes - I have noticed changes in my skills and/or daily lifeNo - I have no noticed changes in my skills and/or daily life

Do you feel that Movement Five has helped you achieve your goals?

Yes - I have achieved some goalsNo - I would like support to achieve my goals

Details of the Feedback you would like to give us:

If you selected 'complaint', please fill out Sections 1, 2 & 3

Section 1 - Complaint Details

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

If Compliant, does this person know you are making this complaint?

Yes No

Does this person consent to the complaint being made?

Yes No

Date the complaint was lodged

What person/organisation is this complaint about?

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

Section 2 - 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.

Section 3 - Supporting Information & Outcome

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

Browse

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

Please wait, files are uploading..