Grievance Process Guide for Recipients of Mental Health Services
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
