Resident/Family Concern and Grievance Form
The CA Room and Board Coalition is a collaboration between Room and Board operators, residents, Behavioral Health, and community providers. The Coalition exists to provide healthy, safe and well-managed housing accommodations for consumers and others.The intent of this form is to support each resident’s right to report grievances (i.e complaints about treatment, care, management of funds, viola1onof rights, lost clothing etc.) and to assure that the coali1on and operators works closely to ensure honesty, integrity and self-advocacy goals are met.
Filer's Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
ANONYMOUS COMPLAINTS ARE NOT ACCEPTED
Property's Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Nature of Complaints
Complaintant's or Avocate's Signature
Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: