Feedback and Complaints Form
Caring Circle Support Network welcomes feedback, compliments, concerns and complaints. Feedback helps us improve the quality and safety of our services.
This form is used to raise matters relating to service quality, participant rights, safety, communication, staff conduct, care, support arrangements, or any other issue connected to service delivery.
Complaints will be managed respectfully, fairly, confidentially and without fear of disadvantage, retaliation or reduced access to services.
Part A – About me :
(If you want to raise this Feedback anonymously, DO NOT complete Part A)
If this Feedback is being raised anonymously, this can be posted by mail to the company’s address.
Is there someone else (legal representative or support person) that you would like involved in making this Feedback?
Yes
No
Name of legal representative/support person
Fill in this box if you are putting this Feedback on behalf of someone else :
Does the person know you are making this Feedback?
Yes
No
Does the person consent to the Feedback being made?
Yes
No
Part B – Feedback Type :
Complaint
Compliment
Improvement
General Feedback
Part C – Details :
What is your Feedback about?
(Provide some details to help us understand your Feedback. You can include what happened, where it happened and who was involved)
Would you like to be contacted regarding your feedback? If so please provide your name and contact details.
(Inform the witness that they may be contacted by the organisation to discuss the matter).
Part D- Outcome- what would you like the outcome of your feedback to be? :
Please return this form to the office or email us
Office Use Only
I,
acknowledge receiving a Complaint Form submitted by
that has been allocated the registration number of
Is this complaint confidential?
Yes
No
Signature:
Date:
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