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Educational Case Management Newcastle Health Services

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Complaint Form

Child First Name *

Child Last Name *

Email

Phone

Street Address

City

State/Province

ZIP / Postal Code

Preferred method of contact

EmailPhone CallText MessageMail

What date did this occur?

Please describe in detail the incident/occasion that needs to be addressed

Who is involved in this complaint? (e.g. clinicians / contractors), individuals, professionals organisations, third party)

In what way has this occasion/issue impacted on you and/or your well-being?

What is the desired outcome from making this complaint?

Have you tried to manage this issue on your own, and if so, how?

Are there any other issues you would like to address which may or may not be associated with this complaint?

Consent and Authorisation

It would assist the Educational Case Management Pty Ltd to have your privacy consent for the purpose of undertaking your complaint. You may choose to remain anonymous; however, it is important to note that without your consent it will be difficult for Educational Case Management Pty Ltd to comprehensively address your concern(s).

I give consent to the Educational Case Management Pty Ltd to disclose my personal information to the clinician (contractor) providing the service, individuals, professionals, organisations, including third parties, involved in the complaint for the purposes of looking into and reporting the complaint.YesNo

I give consent to clinician (contractor) providing the service, individuals, professional, or organisations including third parties, involved in the complaint to disclose my personal information to the Educational Case Management Pty Ltd for the purpose of looking into and reporting on my complaint by Educational Case Management Pty Ltd.YesNo

I wish to remain anonymous *YesNo

I am under the age of 18 *YesNo

Parent/Guardian Details

If you ticked ‘yes’ to the question above, your Parent/Guardian will need to supply their details below:

Parent/Guardian Name

Parent/Guardian Address

Parent/Guardian Email

Parent/Guardian Phone

Preferred method of contact

EmailPhone CallText MessageMail

Full Name

Choose Date

Second signature of parent if required

Full Name

Choose Date

Please do not fill in this field.

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Educational Case Management Newcastle Health Services

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Home
Services
About
Group Programs
Contact

Home
Services
About
Group Programs
Contact

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Services
About
Group Programs
Contact

Contact Us

Office
Unit 3, 56 Hudson St, Hamilton NSW 2303

Phone
(02) 4969 8060

Email
info@ecmonhudson.com

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Educational Case Management Pty Ltd

ABN: 43609946698

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Macquarie University