Complaints and Feedback – PsychSolutions Health and Wellbeing

Personal Details

The information provided below will be used to contact you. Only provide the contact details that you wish to be contacted on.

Title *

Mr
Mrs
Miss
Ms

Name *

Postal Address *

Postcode *

Email *

Phone

Mobile Number *

Details of the Complaint

Is the complaint related to *

Employee of The Company
Service delivery
Volunteer of The Company
Specific incident

What happened? *

Where it happened? *

When it happened? *

Include date if possible.

Who was involved? *

List all persons involved and witnesses if applicable.

Did someone witness the incident? Would they be willing to be contacted regarding your complaint? If so, provide the name and contact details. *

Inform the witness that they may be contacted by The Company to discuss the matter.

Any other relevant details

Have you discussed the matter with the person/s involved? *

If yes, what was the outcome, if any?

If no, is there any reason/s that you cannot do so?

How would you like to see your complaint resolved? What action would you like The Company to take to resolve your complaint? *

Additional information/supporting documentation

Please attach copies (not the original) of any documents that may help us to handle the complaint, e.g. if you have letters, emails, faxes or records of conversations you have had with the person/s associated with the complaint.
To help us resolve this matter as fast as we can, please ensure your contact details are kept up to date. If any of your details change please let us know as soon as you can.

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Date / Time *

Complaint & Feedback Form

Please be assured that all information is strictly confidential.

Personal Details

Details of the Complaint

Additional information/supporting documentation

Orange

Bathurst

Dubbo

Maitland