Client Grievance Form
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mpriceatccusaClient Grievance Form
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mpriceatccusaCLIENT GRIEVANCE
TODAY'S DATE: ___________________ PART 1. TO BE COMPLETED BY CLIENT 1. 2. AGENCY LOCATION/SERVICE SITE: CLIENT NAME, ADDRESS, and PHONE: (How can we reach you?)
3. 4.
CLIENT AGE (if under 18):
PARENT/GUARDIAN NAME (if client is under 18):
DESCRIPTION OF GRIEVANCE (WHAT HAPPENED) Be as specific as you can: Describe when and where this happened, who was involved, date problem occurred, etc.
5.
HOW HAVE YOU ATTEMPTED TO RESOLVE THIS ISSUE?
6.
WHAT ACTION WOULD YOU LIKE THE STAFF TO TAKE TO RESOLVE THIS ISSUE?
(USE BACK SIDE IF MORE ROOM IS NEEDED)
PART II. TO BE COMPLETED BY CATHOLIC CHARITIES AGENCY (within ten (10) working days) Date Received by Agency: AGENCY FINDINGS:
PROPOSED RESOLUTION:
ACCEPTABLE TO CLIENT: ___ Yes ___ No Client intends to move onto the next step in the grievance process: ___ Yes ____ No The next step will be step # _____________ and should be initiated by client by: ________________ A copy of this completed form should be given to the client.
