I am scared for me, my family, my friend because of Scared of fighting hitting violence hurting grabbing punching kicking abuse of bad treatment molesting being neglected being forgotten being ignored misuse mistreatment exploitation this * is happening now will happen soon will happen next time has happened one time has happened many times by * my worker is doing this my carer is doing this my provider is doing this my friend is doing this I * have told no one have told my worker have told my carer have told my provider have told my friend have told the police have told the NDIS My Concern is * New Old, raised once before Old, raised many times before My Concern has been * Ignored Reviewed Investigated Appealed Discussed in mediation Discussed in proceedings My Provider Name Is * My Worker Name is You do not have to provide this information I want to upload photos, videos or files Yes No We will always tell the Provider your issue. We will tell the Provider your details, if this to be a complaint. Upload Here Drop a file here or click to upload Choose File Maximum upload size: 2.1MB Do you want to make this a Complaint Yes No If you want to make a complaint to the Provider, we will need your details. Without your details it will be difficult for us to update you on progress of your issue. First Name * Your First Name - on your Plan Last Name * Your Last Name - on your Plan Email * The email you would like us to send information to Your Phone Number * The number you would like us to call you on Do you want us to contact you or keep you updated on your concerns? Yes No If you want to make a complaint to the Provider, we will need your details. First Name * Your First Name - on your NDIS Plan Last Name * Your Last Name - on your NDIS Plan Email * The email you would like us to send information to Your Phone Number * The number you would like us to call you on If we need to get back to you, how would you like us to do this? Do not contact me Your email Your mobile Carer's mobile Friend's mobile OtherOther Email The email you would like us to send information to Your Phone Number The number you would like us to call you on Carer's Phone Number The number you would like us to call you on Friend's Phone Number The number you would like us to call you on Other Contact Details Other details for us to contact you or someone else for you Additional Support TTY National Relay Service Interpreter Support Person If we need to get back to you, are there additional supports required? Details of Additional Supports Submit
