Incident & Concern Reporting Form

Incident & Concern Reporting Form

(For Foundation Staff or Client)
Use this form to document any concern about a partner provider including missed sessions, billing disputes, client complaints, suspected misconduct, or any other issue that may require Foundation review.

This form may be completed by Foundation staff or submitted by a client. All reports are treated confidentially and reviewed promptly.
Reported By (Name)*

First NameLast Name
Foundation staffClient or client guardianOther providerAnonymousOther
Email (if not anonymous)
example@example.com
Phone (if not anonymous)
Please enter a valid phone number.Format: (000) 000-0000.
Date of Report*

MonthDayYear
Date
Provider Being Reported - Provider Name*

First NameLast Name
Provider Being Reported - Practice / Organization*
Missed or canceled sessions without noticeBilling discrepancy or suspected overbillingSuspected upcodingClient safety concernInappropriate conduct toward clientHIPAA or privacy concernSuspected fraudLicensure concernFailure to respond to Foundation communicationsOther
Date(s) of incident(s)*

MonthDayYear
Date
Client initials (if applicable)
Description of concern*
(Be as specific as possible. Include dates, what happened, and any relevant context.)
NoYes — describe the response below
Description of provider response*
NoYes — with supporting documentation
Upload supporting documentation

Cancelof
Provider Contacted Date*

MonthDayYear
Date
Should be Empty: