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DLRS Home > Grievance Process Guide for Recipients of Mental Health Services > Sample Form - Adult Grievances

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Grievance Process Guide for Recipients of Mental Health Services - Sample Form - Adult Grievances

Department of Behavioral and Developmental Services
Adult Consumer Grievance Reporting Form

Level I
Formal Grievance Filing

Your Name: __________________________             Today's Date: _________________

Address: ___________________________________________________________

Telephone/TTY No.: ___________________________________________________

If you cannot be reached by phone or TTY, how else can you be reached?_______________

Name of Service Provider/Agency Involved: ______________________________________

Location of Service Provider: Town/City: _______________________________________

Date(s) on Which the Grievance Took Place: ____________________________________

Names of People Involved:_________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________

Please Briefly Describe What Happened: (You may use the back of this form if necessary.)

 

 

Please Identify the Specific Issue That Needs to Be Addressed:

 

 

 

Please Suggest How the Matter Can Be Resolved: