Client Concern / Grievance Form
Submit a neutral written concern and your requested follow-up for professional review.
Requester Full Name
*
First Name
Last Name
Your Role
*
Please Select
Visiting Parent
Custodial Parent/Caregiver
Attorney
Social Worker/Caseworker
Guardian
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Surname or Case Name
*
Court Case Number
*
Court County
*
Date of Visit/Exchange/Service Related to Concern (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Concern
*
Service/Scheduling
Communication
Fees/Payment
Monitor Conduct/Professionalism
Safety
Documentation/Report
Policy/Procedure
Other
Describe the concern in your own words
*
What resolution or follow-up are you requesting?
*
Upload supporting document or screenshot (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred method of response
*
Please Select
Email
Phone Call
No response needed
Acknowledgment:
Your concern will be reviewed professionally and neutrally. Submitting a concern does not alter or suspend a court order, confirmed visit, payment obligation, or existing provider policy unless confirmed in writing. This form is not for emergencies; immediate safety threats should be directed to 911 or appropriate emergency services. Information provided may be shared as required by law, court order, subpoena, mandated-reporting duties, or as reasonably necessary to review your concern.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Concern
Submit Concern
Should be Empty: