COMPLAINT FORM

PART A – ABOUT ME

Please tick this box if you would like to remain anonymous.
If you choose to remain anonymous, PART B will be hidden, and you should proceed directly to PART C.

First Name

Last Name

NDIS No. if available

Date

PART B – ABOUT THE COMPLAINANT (if different to above)

PART B - This section will be hidden if you choose to remain anonymous by checking the box above.

Please fill in the section below if you are complaining on behalf of someone else.

Complainant Details

First Name

Last Name

What is your relationship to that person?

Does the person know you are making this complaint?

YesNo

Does the person consent to the complaint being made?

YesNo

Fill in the section below if someone is assisting you with the complaint – for example a family member, your nominee, or a representative.

Name of Representative

Organisation Name

Address

City

State

Postcode

Business Phone

Mobile

TTY

Email

Preferred method of contact

Phone (Business)MobileEmailTTY

PART C – YOUR COMPLAINT

What is your complaint about?

Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved, or the decision made by the Agency that you are unhappy about.

PART D – WHO IS YOUR COMPLAINT ABOUT?

Name of the person, or service about whom you are complaining (the respondent or the Agency person who made the decision)

Contact Name

Organisation

Address

City

State

Postcode

Home Phone

Mobile

Business Phone

TTY

Email

What is this person’s/organisation’s relationship to you?

Do you want to complain about more than one person or organisation?

YesNo

Please provide the details for the additional person below.

Name

Organisation

Address

City

State

Postcode

Home Phone

Mobile

Business Phone

TTY

Email

What is this person’s/organisation’s relationship to you?

What outcomes are you seeking?

PART E – FURTHER INFORMATION

Supporting informationPlease upload copies of any documents that may help us investigate your complaint. For example: letters, references, emails. If you cannot do this, please tell us what you think we should obtain.

Upload Supporting Documents

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Have you made a complaint about this to another agency?

YesNo

If Yes, please provide details of the agency to which you made your complaint and any outcome. Please also attach copies of any letters you have received from that agency.For example: a disability service or equal opportunity agency, Health Care Complaints Commission, Ombudsman.

Upload Supporting Documents

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(e.g., a Provider or another jurisdiction)

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DESIGNER LIFE HEAD OFFICE: 16 Dixon St, Strathpine Q 4500 (07) 3333 2055 ndis@designerlife.com.au www.designerlife.com.au