Als U Niet Tevreden Bent

If you are not satisfied

Complaints form

When should you use this form?

You use this form if you have a complaint, other than a financial complaint, that you would like to submit to the independent Complaints Committee of the Dimence Group.

For whom is this form?

As a client/patient, you can air your discontent by submitting this form. But someone else can also do this on your behalf. This may be a legal representative (parent, guardian, mentor or curator), a person with a written authorisation or a surviving relative. Persons directly involved, such as family of a client/patient, may use this form only when it concerns the manner in which they themselves were approached or informed, not about the approach or treatment of a client/patient.

You are (tick what is applicable)

Client/patient

Ex-client/patient

Legal representative

Person with written authorisation

Surviving relative

Person directly involved

Your data

Complete first and last name:

Address:

Postal code:

Place of residence:

Date of birth:

Telephone number:

E-mail address:

Data of the (former) client/patient on whose behalf you are filling out this form (if applicable)

Complete first and last name:

Address:

Postal code:

Place of residence:

Date of birth:

Description of your complaint: What person, persons, department or agency of the Dimence Group does your complaint concern?

On what date or in what period did this situation occur?

This concerns (tick what is applicable)

Complaint about compulsory admission (Psychiatric Hospitals)

Complaint about something else (General complaint)

I am being supported by a patient confidential advisor (PVP)

Yes/No

Name of the PVP

Regarding your general complaint / Compulsory Admissions Psychiatric hospital complaint: do you want to send one or more attachments?

Indicate here which attachment(s) they are.

Send the form by post or by e-mail to

Administrative secretary to the Complaints Committee [Ambtelijk secretaris klachtencommissie]

Postbus 5003

7400 GC Deventer

More information

More information about the complaints procedure of the Dimence Group can be found in the brochure "If you are not satisfied." ['Als U niet tevreden bent'] This can be found in the brochure racks of the Dimence Group locations or downloaded from our website

Place, ......

Date ......

Signature,

......

The complaints committee will handle your form confidentially and will not use it for purposes other than the processing of the complaint; Your privacy is guaranteed.