WVARR Grievance Form

WVARR Grievance Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
County*
City, State*
Name of the residence in question*
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident move in date*

MonthDayYear
Date
Resident move out date (if applicable)

MonthDayYear
Date
Description of your concern*
Description of what happened when you used the house’s grievance process or a description as to why you did not use the house’s grievance process*
Identification of the quality standard in question. (WVARR will help you identify which quality standards are in question.)
NARR Standard(s) in Question: Please select all that apply to your experience. A check mark indicates that the residence you are filing a complaint about is in violation of that particular standard.*

Residence Operates with IntegrityResidence Upholds Resident RightsResidence is Recovery-OrientedResidence is Peer Staffed and GovernedResidence Promotes Health and SafetyResidence Provides a Home-Like EnvironmentResidence Inspires Purpose in the ResidentsResidence Cultivates a Community Around RecoveryResidence Promotes RecoveryResidence is a Good Neighbor in the Community
What would you like to see happen as a result of this complaint?*
*Grievances must be from a current resident, signed by the resident, and must include an email address and phone number where the resident may be contacted.*
Signature*

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