External Feedback & Complaint Form

Please see our Easy Read Document

Date *

Name & Position of person receiving the feedback

Do you wish to remain anonymous? *

YesNo

Who is providing feedback: *

If other, please specify *

Please provide name and contact details of the person providing feedback:

Name *

Preferred method of contact *

Phone callEmailLetter

Phone Number *

Email Address *

Postal Address for Letter *

Feedback or Complaint Details

Please provide some details to help us understand your concerns, including what happened, where it happened, time it happened and who was involved.

Description: *

What action would you like us to take? *

Please attach copies of any documentation that may help us to investigate your complaint/feedback (letters, references, emails).

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Thank you for your feedback.

Admin Feedback Resolution

Type of feedback *

PositiveNeutralNegative

Contact made with person

Further info on discussion with person who gave feedback

Contact made with Client

Further info on discussion with Client

What actions have been proposed? Or if resolved, how was this feedback resolved? *

Discussed with Therapist

Details provided on Actions taken to person giving feedback

Resolution info to provide to Person *This information is sent on the automated workflow to the person who provided the feedback

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