Tickit on Demand - headspace National Youth Mental Health Foundation

This is the headspace National Feedback Form.

This form is used to record any compliments, complaints and / or suggestions about headspace programs and services.

If you need help completing this form, you can call us on 03 9027 0100

headspace Service

Program Area^*

Is your feedback in relation to a headspace centre?

YesNo

headspace Centre Name

Type of Feedback^*

ComplimentComplaintSuggestion

Feedback^*

Tell us about your experience. For example, what happened, when it happened, and who was involved.

Tell us how you would like us to help

The information you share helps us to communicate with you in the best way possible.

What is your name?

You don't have to tell us who you are if you don't want to, but it might make it harder for us to investigate your feedback fully.

What are your pronouns? For example: She/Him/They

We ask for pronouns so we can create a safe, inclusive space for everyone.

Phone Number

Sharing your phone number helps us get in touch with you about your feedback if needed.

Email Address

Sharing your email gives us another way to get in touch with you about your feedback if needed.

Preferred Contact Method

Let us know how you would like to be contacted.

PhoneEmailI don't want to be contacted about my feedback

Are you a...

Other

Please detail

How were you informed of the Feedback?^*

Include specific details such as phone call to reception, email to info@headspace.org.au etc...

Please attach documents/emails to this complaint at the bottom of the form.

Other Way Received

Please detail

Date Informed of Feedback^*

Feedback Provider's Name

Feedback Provider's Contact Details

Did you advise person of the feedback process including response timelines^*

Is there anything else we should know to help you?

Do you consent to headspace publishing your compliment to promote headspace services and encourage help seeking behaviour?^*

YesNo