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.
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."

I prefer follow-up communication by Phone callI prefer follow-up communication by EmailI don't have a preference, both Phone call or Email work for me for follow-up communication.
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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