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ABA Ops Compass

Policies and Procedures

04Sources

Back to Client & Caregiver Complaint Policy

Appendix 28

Client and Caregiver Complaint Form

Active clinic: [Company]

Use this form to submit a complaint about services. Submissions are logged on receipt and reviewed in accordance with the Client and Caregiver Complaint Policy. Filing a complaint will not result in retaliation.

Complainant Information

Name *

Date submitted *

Relationship to Client

Parent
Legal Guardian
Client
School Staff
Other

If Other, Specify

Phone

Email

Client Information

Client name *

Date of birth

Primary analyst (if known)

Nature of Complaint

Type of concern (check all that apply)

Quality of services
Staff conduct
Communication
Safety concern
Scheduling
Billing
Documentation
Ethical concern
Other

If other, specify

Describe the concern in detail. Include dates, staff involved, and any relevant information. *

Requested Resolution (Optional)

Certification

I certify that the information provided is accurate to the best of my knowledge.

Printed name *

Date *

Signature *

Sign here

Draw with mouse, finger, or stylus.

For Internal Use Only

Date received

Received by

Complaint logged

Investigation required

Corrective action required

Resolution summary attached

Date of initial response

Date closed

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