COMPLAINT/GRIEVANCEFORM

COMPLAINT/GRIEVANCEFORM

70-163 Rev. 04/16
Pathways, Inc. is interested in hearing any complaints and/or grievances you may have with our organization. We will do our best to remedy the situation. Please complete as much of the requested information as you can by checking the appropriate boxes and providing as much descriptive information as possible.
Date

MonthDayYear
Date
Professional number of staff taking information (if applicable):
ORIGIN

CONSUMER – check this box if you are receiving a service provided by Pathways.VISITOR – check this box if you are neither an employee of Pathways nor do you receive any servicesprovided by Pathways.STAFF – check this box if you are a current Pathways’ employee.
SERVICE AREA

MENTAL HEALTH – check this box if your issue involves the Mental Health Program.PREVENTION SERVICES – check this box if your issue involves Regional Prevention Center services.DEVELOPMENTAL DISABILITIES – check this box if your issue involves developmental and/orIntellectual disabilities services.SUBSTANCE ABUSE – check this box if your issue involves the Addiction Services Program.COMPUTER SERVICES – check this box if your complaint stems from computer equipmentor services.FLEET/FACILITIES/PURCHASING/TELEPHONE SERVICES – check this box if your issue involvesany of these areas.HUMAN RESOURCES – check this box if your complaint involves Pathways’ staff, employeebenefits, supervisory issues, and/or agency policies/procedures.Other
OFFICE LOCATION

BathBoydCarterElliottGreenupLawrenceMenifeeMontomgeryMorganRowan
COMPLAINT RELATES TO

SERVICE STAFF/CASE MANAGER – check this box if the area of complaint involves directservice providers (counselor, case manager, etc.).CLERICAL STAFF – check this box if the area of complaint involves office support staff.SERVICE SYSTEMS – check this box if you have complaints about how we provide services(timeliness, efficiency, professionalism, confidentiality).PAYROLL – check if complaint is about Pathways’ payroll system.BILLING – check if complaint involves Pathways’ billing system.ACCOUNTS PAYABLE – check if complaint involves Pathways’ accounts payable system.TELEPHONE SERVICES – check if complaint involves Pathways’ telephone services.FLEET SERVICES – check if complaint involves Pathways’ fleet services.BUILDING/SITE – check if complaint involves a physical structure and/or its systems.PURCHASING/SUPPLY – check if complaint involves Pathways’ purchasing system and/orsupplies and materials.PERSONNEL/EMPLOYEE BENEFITS – check if complaint involves Pathways’ staff, employee benefits,supervisory issues, agency policies/procedures.
DESCRIPTION OF SITUATION: If applicable, check the box next to the category(ies) involved in your complaint:

Customer Service/Rude BehaviorClinical PracticeFacility CleanlinessUntimely ResponseFacility MaintenanceInconvenient Service HoursFacility Inconvenience
Please give details of your complaint below:
Description of situation:
Proposed Solution (please provide remedies to this Complaint here):
OPTIONAL: If you would like to talk with someone about your complaint or be contacted when an outcome has been determined; please provide your name, address, and phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A self-addressed, stamped envelope is available from the Customer Service Manager upon request, or mail to:

Pathways, Inc. • P.O. Box 790 • Ashland, KY • 41105-0790

ATTN: Chief Compliance Officer
Should be Empty:

COMPLAINT/GRIEVANCEFORM

OPTIONAL: If you would like to talk with someone about your complaint or be contacted when an outcome has been determined; please provide your name, address, and phone number.