SunServe Client Grievance Form
Please complete the following information completely. This form will be submitted to the VP of Operations, Gary Hensley, at ghensley@sunserve.org. Upon submission, the VP of Operations will reach out to you within 7 business days.
Complainant Information
If you wish to remain anonymous, you may choose to submit this form without providing any identifying information. Please note that you will not be reached out to with any updates or with the final resolution regarding your grievance. Due to privacy and confidentiality, if you submit a grievance anonymously, the agency will not be able to confirm or deny or provide any updates regarding your grievance.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Grievance Information
Program
*
Staff
*
Type of Grievance
*
Details of the Grievance (Include dates and times, names of person(s) involved)
*
Have you attempted to discuss this complaint with the individual?
*
Yes
No
If yes, give details below.
What is your desired resolution?
*
Resolution Process
Please indicate the course of action you wish to proceed with:
*
This is for information purposes only. I do not want proceed further with this complaint.
I want to pursue a formal grievance process.
I do not want to request formal grievance process, but I do want to meet with the staff member below (please select the staff member below that you wish to meet with).
If you wish to meet with a staff member to discuss your grievance, please select the staff member(s) below:
Program Director
Human Resources
Quality Assurance
Executive Director
If you wish to upload any supporting documents related to your grievance, please do so below.
Browse Files
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of
Signature
If you wish to remain anonymous, please do not sign this form.
Date
*
-
Month
-
Day
Year
Date
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