Complaint or Concern Form
Share your complaint or concern, including incident details and any requested resolution, and submit securely.
Person Submitting the Complaint
Are you submitting anonymously?
*
Yes
No
Full name
First Name
Middle Name
Last Name
Relationship to the client
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Preferred contact method
Please Select
Phone
Email
Text
May the office contact you?
Yes
No
Keep my identity confidential when reasonably possible
Yes
No
Client Information
Client Name
First Name
Middle Name
Last Name
Service Address or City
Complaint Details
Type of Complaint
*
Please Select
Quality of care
Caregiver conduct
Office staff
Scheduling
Missed or late visit
Communication
Billing
Privacy
Discrimination
Safety
Abuse/neglect/exploitation
Property concern
Other
Date and Approximate Time of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
Name or Role of Person Involved
Detailed Description of What Happened
*
Were There Any Witnesses?
Yes
No
Is the Concern Ongoing?
Yes
No
Is Anyone Currently in Danger?
*
Yes
No
Urgent Safety Notice
Previous Reporting and Resolution
Was this concern previously reported?
*
Yes
No
Date reported
-
Month
-
Day
Year
Date
Reported to
What action was taken?
What resolution is being requested? / Additional comments
Certification
Certification
*
I certify that the information provided is true and accurate to the best of my knowledge.
Electronic Signature
Date
*
-
Month
-
Day
Year
Date
Submit Complaint
Submit Complaint
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