Client Grievance Submission Form

Use this form to report any concerns or grievances regarding peer support services. Your submission will be reviewed by a neutral peer, and all information will be handled confidentially.

First name

Last name

Date

Month

Day

Year

Phone

Preferred Method of Contact

Phone

Date and Time of Incident

Month

Day

Year

Time

HoursMinutes

Location of Incident

Describe the location to the best of your ability. If this occured in a digital enviroment, describe that service or platform.

Brief Description of Concern

Provide a concise summary of your grievance.

Desired Outcome

What resolution would you consider satisfactory?

Additional Information

Is there anything else you feel is important to share?

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

Sign your name to serve as your signature.

Signature field is empty.

Client Grievance Submission Form

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