Grievance Form

Grievance Form

Use this form to submit a formal grievance that concerns Laurel Hill Center service delivery, service quality, or staffing issues.
Date of Form Submission

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Please Note: We request an email address so that you can receive a copy of the information you submitted on this grievance form.
How would you prefer to receive follow-up communication regarding your grievance? Please select the option that best matches your preference."
Name of LHC Primary Staff (leave blank if none or unknown)
Please provide a detailed description of the issue or concern that led to your grievance. Include specific events, dates, and individuals involved, if applicable.
What steps or actions do you believe would help resolve this grievance to your satisfaction?
If someone assisted you with this form, please list their name.
Signature
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