Client Complaint Form
Do you have a concern about the NHBP Health and Human Services Department's service(s) or clinic's operations? Please fill out the form below.
Client Record Number
Name
*
First Name
Last Name
Date of Complaint
*
-
Month
-
Day
Year
Date
Time of Complaint
*
Hour Minutes
AM
PM
AM/PM Option
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Received
*
Please Select
Medical
Behavioral Health
Physical Therapy
Dental
Clinic Location
*
Please Select
Grand Rapids
Pine Creek
NHBP Health at FireKeepers
Description (Briefly describe complaint, provide dates, times, location and persons involved; if complaint is written, attach copy and other supporting documentation):
*
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What are your views and expectations?
*
Who has been involved and/or affected?
*
Names and numbers of any other individuals or agencies you have contacted:
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