Complaint Form - CA Care Services

Part B - About the complainant (if different to above)

Fill in this section if you are complaining on behalf of someone else

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

Name of representative:

My preferred contact is:
BusinessMobileFaxTTYEmail

Part C - Your Complaint

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.

What is your complaint 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)

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

What outcomes are you seeking?

Part E – Further information

Please attach 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.

Have you made a complaint about this to another agency?
YesNo

(For example: a disability service or equal opportunity agency, Health Care Complaints Commission, Ombudsman.)
If so, 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.

Please check this box to consent to the National Disability Insurance Agency providing information to a third party (e.g. a Provider or another jurisdiction) to resolve your issue.