Customer Feedback Form

This form is to assist you in providing feedback to our organisation

- All persons wishing to provide a feedback can speak with the Manager or staff member of choice or choose to complete this form.
-All information is strictly confidential.
- If you feel unsure about anything or would like help to complete this form, please speak to the admin person
-We encourage you to provide your feedback in writing. Please allow a maximum of ten (10) days for a response.
-Please attach copies (not the original) of any documents that may help us to handle the feedback.
-If you still wish to provide this feedback about us to the NDIS commission, please contact 1800 035 544

Source: *

Participant
Worker
NDIS
Other

Part A - About Me

(If you want to provide this feedback anonymously, DO NOT complete Part A)
If this feedback is being provided anonymously, this can be posted by mail to the company’s address.

Date

Full Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Is there someone else (legal representative or support person) that you would like involved in proving this feedback?

Name of legal representative/support person

Fill in the below section if you are providing this feedback on behalf of someone else

Name Of Person

First

Last

What is your relationship to that person?

Phone Number

Does the person know you are providing this feedback?

Does the person consent to the feedback being made?

Part B – Your feedback

What is your feedback about?

(Provide some details to help us understand your concerns. You can include what happened, where it happened and who was involved)

Did someone witness the incident?

Would they be willing to be contacted regarding your feedback? If so, provide the name and contact details. (Inform the witness that they may be contacted by the organisation to discuss the matter).

Part C - How can we help to fix this problem or feedback?

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NDIS
Contact
SIL Locations
Privacy Policy

Supported Independent Living (SIL)
Community Participation
Day Options
In-Home Care

(08) 8165 0300
28 Darley Road, Paradise SA 5075
hello@kdservices.com.au
Kangaroo Disability Services
@kangaroodisabilityservices

In the spirit of reconciliation Kangaroo Disability Services acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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