NDIS Feedback and complaints form

Connect Allied Health Hub- Feedback and complaints form

PATIENT DETAILS

First Name *

Last Name *

Preferred Mobile *

Date of Birth *

Preferred Email *

Email Address

When can we contact you *

Morning AfternoonAnytime

Are you making this complaint on behalf of a person with disability? *

YesNo

Do you require any help with communication? e.g Interpreter or National Relay Service? *

YesNo

Tell us about your complaint You may wish to include details such as: •the date and time the incident(s) occurred •an outline of the issues involved, and •whether the complaint relates to a current service provider. *

Have you spoken to your provider? *

YesNo

Name OR Authorised Signatory Name *

Date of Signature *

Authorised Signature *

Clear

One of our team with be in touch with you within 7 business days with an acknowledgement of complaint.
Please reach out to our team on 07 4661 5577 or email ndis@cahh.com.au.