Grievance Process Guide for Recipients of Mental Health Services

Level 1 Grievance Reporting Form Word* or PDF* (*free viewer)

Dept. of Health and Human Services
Office of Adult Mental Health Services

Level 1 Grievance Reporting Form

Today’s Date: _____________

Your Name: _____________________________________________

Address: _______________________________________________

_______________________________________________

Phone/TTY: _____________________________________________

Name of Agency/Service Provider Involved:
_______________________________________________________

_______________________________________________________

Location of Agency/Service Provider (city/town):

_______________________________________________________

Date(s) that the incident happened: __________________________

Name(s) of People Involved: ________________________________

_______________________________________________________

Briefly Describe What Happened (use the back of this form if necessary):

What is the specific issue that needs to be addressed?

How can this matter be resolved?

Your Notes and Contact Information