Relationship with service
How is the person lodging the feedback related to the service?
Person Lodging Feedback
Please provide contact details so we can follow up with you.
Is this feed back being lodged on behalf of another person?
Does the person know you are making feedback on their behalf?
Are you a legal representative of this person
eg Parent / Guardian/ Right of attorney/ NDIS nominee etc
Are we able to speak with the person who receives the service?
On behalf of whom are you lodging this feedback?
(If different to person lodging form)
Do you require an interpreter?
Parent or Guardian of Client
If different to person lodging feedback
What Program does this service relate to:
Please specify Other program
What Location does this service relate to:
Please provide address of location
HIDDEN Which Day Program
Details of Feedback
Please provide details of your main concerns, including the events that led to making the compliment, complaint or feedback. If possible please include appropriate dates and who was involved
Please attach any supporting files (Optional)
Have you discussed your concerns with the service provider or another agency/person for assistance with these concerns?
Please provide details of previous conversations/ contact about this feedback
Please provide any information you have available to assist us . Who did you speak to , What was said / done , When any previous conversation/s occurred.
What would you like to see done about this feedback?
Employee completing form
Please provide details of legal relationship
The Richmond Group is committed to protecting your privacy. We collect and handle personal information that you provide on this feedback form for the purpose of investigating and responding.
The organisation will only use your information in accordance with relevant privacy and other laws.
If you have chosen to remain anonymous, we may be unable to provide you with a response about the outcome of the actions taken as a result of your feedback.
Please tick the below box to indicate that all information you have provided is true and correct
Thank you for taking the time to provide us with this feedback.
This field will be automatically updated by sign off process.
Not all fields have been entered correctly