Feedback – DMI Psychology

Personal Details

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

Salutations

Name*

Postal Address*

Email Address*

Contact Number*

Details of Complaints

Is the complaint related to:

Employee of DMI PsychologySpecific Incident

Service DeliveryOther

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 DMI Psychology to discuss the matter)

Any other relevant details:*

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

YesNo

If yes, what was the outcome, if any? (if no, is there any reason/s you cannot do so?)*

How would you like to see your complaint resolved? What action would you like us 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.

Form Submission*

This form collects personal and detailed information for the purposes of managing a feedback or complaint against
DMI Psychology services or providers. This information may also be used for the continual improvement of our
service, as well as any disciplinary measures required to address the feedback or complaint. Your information is
bound by the relevant Australian privacy legislations. and will be recorded in accordance with our legal obligations.
By submitting this form, you confirm that you understand how your information will be managed, and for the Principal
Psychologist to contact you in order to come to a resolution.

I AgreeI Disagree

Additional information / support doucmentation 1

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Feedback & Complaints Form

Please be assured that all information is strictly confidential.

Personal Details

Details of Complaints

Additional information/supporting documentation

Form Submission*