Date
About you
Your Name
Your Phone Number
Your Email
About the person who the complaint was made about (if applicable)
Name:
About the affected child or young person in the complaint
Name:
Age:
Gender:
Complaint description (accurately record the issues, who was involved in the incident or complaint and their role, details of any witnesses) as far as possible in the child/young person’s own words/ or in your own words:
Diversity details relating to the affected child or young person
If any of the following are relevant to how we can best support the child or young person, please let us know.
Do they identify as Aboriginal or Torres Strait Islander?
Please answer Yes or No. If Yes please specify:
Are they from a culturally and linguistically diverse background?
Please answer Yes or No. If Yes please specify:
Are they in out-of-home care?
Please answer Yes or No.
Do they have a disability?
Please answer Yes or No. If Yes please provide relevant details:
Do they have communication support needs?
Please answer Yes or No. If Yes please provide relevant details:
Do they have an alternative preferred sexual orientation and/or gender identity?
Please answer Yes or No. If Yes please provide relevant details:
Provide any other relevant information relating to the child or young person that can assist in addressing the complaint:


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