Grievance Report Form
We understand that reporting a concern can be difficult, and we appreciate you bringing this matter to our attention. Please provide as much detail as you are comfortable sharing so that we can thoroughly investigate and improve our services. Please note that this form is confidential. While you may choose to remain anonymous, please be aware that if no contact information is provided, we will be unable to follow up with you directly regarding the resolution of your grievance.
Please note: This form is intended for non-urgent matters only. If you are reporting an urgent concern—such as a risk to client or staff safety, suspected abuse, or an immediate attendance issue—please contact our on-call staff member directly at 603-930-0884. By proceeding, you confirm that this inquiry is non-urgent and can be addressed during our next business day.
I confirm that this is a NON-URGENT matter
Your Full Name
First Name
Last Name
Your Email Address
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident
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Month
-
Day
Year
Date
Location of Incident
Staff Member(s) Involved (if applicable)
Type of Grievance
*
Please Select
Service Quality
Staff Conduct
Communication
Billing/Payment
Other
Describe Your Grievance
*
Desired Resolution/Outcome
Upload Supporting Documents (optional)
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