Coordinated Entry Grievance Form

Coordinated Entry Grievance Form

This form is for individuals who wish to file a formal complaint or grievance regarding services or experiences related to the Coordinated Entry system in Anchorage. This includes concerns about access, assessment, referral, or treatment by any participating agency or staff member.
🖨️ You can also print this form and mail or drop-off to: 3427 E Tudor Rd. Suite 200

Click here to download.
Complainant Information
Grievance Type
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred method of contact
Safe to leave a message?
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location/Agency Involved
Grievance Details
Please describe your concern or complaint
Have you attempted to resolve this issue directly with the agency or staff member involved?
If yes, what was the outcome?
What resolution are you seeking?

Other
Other resolution (please specify)
Signature
Date (Signature)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only DO NOT FILL OUT
Office Use Only
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Received by
Status
Date of Resolution

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notes/Action Taken
Should be Empty: