T4C Make a Complaint

Purpose:

Ark Alliance Recovery, LLC is committed to providing quality care in a safe and respectful environment. Clients have the right to file a complaint without fear of retaliation. All complaints will be reviewed and responded to within 72 hours.

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Section 1: Client Information

Client Name:

Date of Birth

Month

Day

Year

Phone Number

Email Address

Preferred Method of Contact:

Phone

Either

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Section 2: Complaint Information

Date of Incident:

Month

Day

Year

Time of Incident:

Time

Name of Staff Involved (if applicable):

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Section 3: Description of Complaint

Please describe your complaint in detail. Include names, dates, and specific information.

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Section 4: Requested Resolution

What would you like to see happen to resolve this matter?

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Section 5: Client Signature

I certify that the information provided is accurate and truthful to the best of my knowledge.

Signature

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

Date

Month

Day

Year

T4C Make a Complaint

Purpose:

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Section 1: Client Information

Client Name:

Date of Birth

Month

Day

Year

Phone Number

Email Address

Preferred Method of Contact:

Phone

Either

-----------------------------------------------------------

Section 2: Complaint Information

Date of Incident:

Month

Day

Year

Time of Incident:

Time

Name of Staff Involved (if applicable):

-----------------------------------------------------------

Section 3: Description of Complaint

Please describe your complaint in detail. Include names, dates, and specific information.

-----------------------------------------------------------

Section 4: Requested Resolution

What would you like to see happen to resolve this matter?

-----------------------------------------------------------

Section 5: Client Signature

I certify that the information provided is accurate and truthful to the best of my knowledge.

Signature

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

Date

Month

Day

Year