Grievance and Concern Form
We want to hear from you. Doors of Change is committed to providing respectful, fair, and supportive services. Use this form to share a concern, complaint, or grievance about your experience with our program, services, staff, volunteers, or partners. This form is not monitored for emergencies. If you are in immediate danger or need urgent help, call 911.
Date
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Month
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Day
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Your Information
You may submit this form anonymously. Please know that if you do not include contact information, we may not be able to follow up with you directly.
Name (Optional):
First Name
Last Name
Phone Number (Optional):
Please enter a valid phone number.
Format: (000) 000-0000.
Email (Optional):
example@example.com
Preferred Contact Method:
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Phone
E-mail
No follow-up needed
Your Concern
What is your concern related to?
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Doors of Change services or support
A staff member
A volunteer
A partner organization
Access to services
Discrimination, unfair treatment, or harassment
Privacy or Confidentiality
Other
Date of Incident or Concern (Optional):
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Month
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Day
Year
Date
Name of Person or Program Involved (Optional):
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Please tell us what happened.
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Include as much detail as you feel comfortable sharing, including what happened, when it happened, and who was involved.
What would you like to see happen or be resolved? (Optional):
May Doors of Change contact you for more information?
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Yes
No
I am submitting anonymously
If yes, When is the best time of the day to contact you?
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Submission Confirmation
I understand that Doors of Change will review my concern and may contact me if I provided contact information.
Submit Grievance
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