Complaint Form

Any client, parent, legal guardian, school staff member, or other party may use the Complaint Form to raise a concern with [Company]. The form is the primary written intake instrument for the Client and Caregiver Complaint Policy and feeds the Grievance Procedure when escalation is needed.

The Complaint Form on the right captures the complainant’s identifying information and relationship to the client, the client’s basic information, a detailed description of the concern (dates, staff involved, relevant context), the type of concern (quality of services, staff conduct, communication, safety, scheduling, billing, documentation, ethical concern, or other), and an optional requested resolution. The complainant certifies the information is accurate and signs.

The bottom of the form is reserved for internal use and captures the date received, who received it, whether the complaint was logged, whether an investigation is required, the date of initial response, whether corrective action is required, whether a resolution summary is attached, and the date closed. Completed forms are filed in the complaint log with any supporting documentation.