Client Grievance Form

Facility Name

Program Name (if applicable)

Our goal is to provide safe, respectful, and effective services. If you have a concern or complaint about your care, staff conduct, or program services, you have the right to file a grievance without fear of retaliation

Please complete this form and return it to staff, the Program Director, or place it in the grievance box (if available).

Client Information

Client Name

Date of Birth

Month

Day

Year

Phone Number (Optional)

You may file this grievance anonymously if you prefer.

I wish to remain anonymous

Details of Your Concern

Date(s) of incident:

Location of incident:

Person(s) involved (if known):

Please describe your concern in detail:

Have you spoken to anyone about this concern already?

Yes - if yes, who did you speak to?

What outcome or resolution are you hoping for?

Signature

Client Signature (optional if anonymous)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

__________________________________

For Office Use Only

Date Grievance Received: _____________________________________

Received By: _______________________________

Action Taken:

____________________________________

______________________________

Date of Response to Client: _______________________________

Resolution:

_______________________________________

____________________________________

Staff Signature: _________________________________________

Date Closed: ___________________________

______________________________________

Client Rights Regarding Grievances

You have the right to file a grievance without retaliation.
Your concern will be reviewed promptly and fairly.
You will receive a response within ______ days.
If you are not satisfied with the outcome, you may request further review.

Client Grievance Form

Facility Name

Program Name (if applicable)

Please complete this form and return it to staff, the Program Director, or place it in the grievance box (if available).

Client Information

Client Name

Date of Birth

Month

Day

Year

Phone Number (Optional)

You may file this grievance anonymously if you prefer.

I wish to remain anonymous

Details of Your Concern

Date(s) of incident:

Location of incident:

Person(s) involved (if known):

Please describe your concern in detail:

Have you spoken to anyone about this concern already?

Yes - if yes, who did you speak to?

What outcome or resolution are you hoping for?

Signature

Client Signature (optional if anonymous)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

__________________________________

For Office Use Only

Date Grievance Received: _____________________________________

Received By: _______________________________

Action Taken:

____________________________________

______________________________

Date of Response to Client: _______________________________

Resolution:

_______________________________________

____________________________________

Staff Signature: _________________________________________

Date Closed: ___________________________

______________________________________

Client Rights Regarding Grievances

You have the right to file a grievance without retaliation.
Your concern will be reviewed promptly and fairly.
You will receive a response within ______ days.
If you are not satisfied with the outcome, you may request further review.