Consumer Grievance Form

Consumer Grievance Form
Date of Grievance

MonthDayYear
Date
Time of Grievance

Hour Minutes

AM/PM Option
Name of Individual Filing Grievance

First NameLast Name
Client name if different from person filing

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Grievance Reason: (please provide as much detail as possible, persons involved etc.)
What outcome or remedy are you seeking?
It is the policy of Bridges Core Service Agency, Inc. that the persons served are encouraged to state complaints and/or grievances if they believe their rights have been violated, and to pursue a resolution to their concerns in a structured format that provides fair and equitable results through due process.

During a formal grievance procedure, the person served will have the right to the following:
- Assistance by a representative of his/her choice.
- Review of any information obtained in processing the grievance, except that which would violate the confidentiality of another person served.
- Presentation of evidence of witnesses pertinent to the grievance.
- Receipt of complete findings and recommendations, except those that would violate the confidentiality of another person served.
Should be Empty: