Client Grievance Form

Grievance Form

1. This form is to be completed if you have a grievance/concern that you have already addressed with a team lead or other supervisor which, in your opinion, has not been satisfactorily resolved. You may also call your regional office to file a grievance.

2. Complete this form and a meeting (in person, through tele-health, or over the phone) will be scheduled within 3 business days.

3. Once a decision has been made someone will contact you with that decision and you will have the right to appeal it. All appeals go to QAQI and they will reach out to you.

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* 1. What is the best way to reach you? ( if you wish to be anonymous please skip)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Which office location do you receive services from?

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* 3. Date/time and location of event

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* 4. Please list any witnesses

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* 5. Please provide a detailed account of the occurrence. Include the names of any additional persons involved:

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* 6. Please provide what rights you believe were violated

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* 7. Please provide a proposed solution (what would you like to see happen to rectify this event)

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* 8. You may request a copy of this form by e-mailing nspringer@pridenc.com. By checking the box below, you agree that the information you are submitting is truthful.

I attest that my statements are true.