Feedback, Complaints and Compliments

Your feedback is important to us. It helps us improve, so that you will feel safer, happier and get more out of our services. Your feedback is kept private. If you wish to remain anonymous, please leave the following section blank.

Client's Name

Client's Representative's Name (if applicable)

Date

Please select the service and/or practitioner that the feedback, compliment or complaint refers to:

Service

Speech PathologyOccupational TherapyBehaviour SupportPsychologyTherapy AssistantSupport CoordinationAdministrationOther

Your Clinic Location

Ballarat Bacchus MarshSupport Coordination

Practitioner (if applicable)

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FeedbackComplaintCompliment

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Record

How was the feedback received?

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Action

Outcome

Status

Open Closed

Additional Comments

Signature

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Date Signed

Name

Position

Review

Date Reviewed

Further Action Required

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Date Signed

Name

Position

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