CLIENT GRIEVANCE / COMPLAINT FORM
Date of Grievance/Complaint
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Type of Complaint
Please specify the type of complaint (e.g., abuse, neglect, harm, or noncompliance).
Name of Individual Affected by Grievance/Complaint
Please provide the name of the individual/client experiencing the described grievance.
Description of Grievance/Complaint
Please provide a detailed description of the grievance, including the nature of the problematic event, the individuals involved, the frequency of the grievance occurrence, and any resolutions reached in hindsight.
May we contact you for future investigation?
Yes
No
If yes, please write your e-mail address
example@example.com
Submit
Should be Empty: