Civil Right Discrimination Complaint Form

CIVIL RIGHT DISCRIMINATION COMPLAINT FORM
NAME
DATE OF BIRTH

MonthDayYear
Date
PHONE NUMBER
EMAIL
example@example.com
STREET
CITYSTATE
ZIP CODE
Are you filing this complaint for someone else?

YesNo
If Yes, whose civil rights do you believe were violated?
NAME
DATE OF BIRTH

MonthDayYear
Date
I believe that I have been (or someone else has been) discriminated against on the basis of:

Race/EthnicityNational OriginAgeReligion/ConscienceSex/GenderLanguage BarrierSexual OrientationDisabilityOther
When do you believe that this occurred? List Date(s)*
Describe briefly what happened. How and why do you believe you have been discriminated against? Please be as specific as possible.
Names of individuals involved or witnesses if known:
What action or resolution are you seeking?
Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.
SIGNATURE

Clear
DATE

MonthDayYear
Date
Filing a complaint is voluntary. However, without the information requested above, Emerald Therapy Center may be unable to proceed with your complaint.

Submit the completed to the Chief Compliance Office

By mail: 2327 New Holt Rd, Paducah, KY 42001

By email: compliance@emeraldtherapycenter.com

If completing via the Emerald Therapy Center website, this form will be directly submitted to the Chief Compliance Office.

For assistance, call: (270) 534-5128
Should be Empty: