Grievance Form
This form can be submitted without personal information. This form will only collect the personal contact information you provide in the form fields. Items marked with and asterisk (*) are required in order to submit this form.
Gavia Life Center Grievance forms are received by the Executive Director.
1. Please describe the scenario that prompted you to file a grievance.
*
Enter your answer here.
2. How would you like Gavia to respond?
*
No response needed. I just wanted to let you know.
I'd like to be contacted by a supervisor.
I'd like to switch providers.
Other
3. If a response is requested, please provide the best method to contact you.
Phone Call
Text (This response will require providing your "mobile phone number" below.
Email
Please enter your mobile phone number if applicable.
Please enter a valid phone number.
Format: (000) 000-0000.
Please enter your Email if applicable.
example@example.com
Please enter your name if applicable.
First Name
Last Name
Submit
Should be Empty: