Client Grievance Form

Thank you for bringing your concerns to our attention. We are committed to providing high-quality, respectful behavioral health services. Your feedback helps us improve. Please complete this form to initiate a formal grievance review. You will receive a response within the BHA-mandated timeframe.

Full Name

Date

Phone Number

Email address

Preferred Method of Contact:

Phone

Mail

Person Submitting Form (If different from Client)

Your Name:

Relationship to Client:

Contact Phone/Email:

Details of the Grievance

To help us investigate effectively, please provide as much detail as possible.

Date(s) of Incident:

Name(s) of Staff Member(s) Involved (if applicable):

Type of Grievance:

Quality of Care / Clinical Services

Staff Behavior / Communication

Client Rights / Privacy Concerns

Billing / Financial Dispute

Facility Safety / Cleanliness

Other (Please specify)

Description of the Incident:

Please describe what happened, where it happened, and any relevant details.

Desired Outcome

What action or resolution are you seeking?

Acknowledgement & Digital Signature

By signing below, I certify that the information provided is true and accurate to the best of my knowledge. I understand that this grievance will be investigated securely and confidentially in accordance with BHA regulations and HIPAA guidelines.

Digital Signature (Type Full Name):

Date

Your information will be encrypted.