Client Grievance Form

Client Grievance Form

If you have a concern about Paperflower Foundation or one of our partner providers, we want to hear from you.
This form is completely confidential. You will not lose your funding for raising a concern in good faith.

Submit to info@paperflowerfoundation.org or mail to our address on our website.
Your Name (optional — you may submit anonymously)

First NameLast Name
PhoneEmail
Date*

MonthDayYear
Date
A partner providerPaperflower Foundation staff or processesA billing or payment issueHow I was treatedMy funding being reduced or stoppedOther
If other(s), please share your concern here:
Provider name (if concern is about a provider)*

First NameLast Name
Please describe your concern if it's about a provider.*
What would you like to happen?*
We will acknowledge receipt of your concern within five (5) business days and follow up with you directly if you have provided contact information.
Should be Empty: