Click for Client Grievance Guide Submitter's NameName of the individual filing this grievance. If your name is not provided this may limit us in our ability to resolve grievance. First Last Program(Required)Please provide the name of the Program where the Grievance is being filed.Bright Start ChildcareNurturing Parenting ProgramParents as TeachersDoulasMental Health Juvenile JusticePositive Parenting ProgramWraparoundCounseling & Wellness CenterIn-Home-IntensivePositive Parenting ProgramFoster CareTransitional & Independent LivingYouth HomeGroup HomeOtherWhat are you filing a grievance/complaint about?Recommendations may not be the final solution.What right(s) have been violated?You can select multiple options. If Other is chosen, please explain below. Freedom from abuse/neglect Adequate/humane care Privacy Appropriate treatment services Confidentiality Right to possess property Right to refuse services Right to file a grievance Notification of right restrictions Right to accommodations Freedom from exploitation Not treated with respect/dignity Right to mail/phone/visits or right to review file Language/communication rights Receive services without discrimination Contact Guardianship, Advocacy, or Placement Agency Rights guaranteed by law Active in treatment planning Notification of med side effects Appropriate use of restraint/seclusion I don't know Other (please explain below)OtherIf Other is chosen as rights violated, please provide an explanation here.What would you like to see happen in response to your grievance/complaint?Contact Phone #Provide your phone # to allow us to contact you.Contact EmailProvide your email address to allow us to contact you.
