GRIEVANCE, SUGGESTION, COMPLAINT FORM

1. Please describe your grievance, complaint or suggestion.

 

 

 

 

 

2. Describe what attempts you have made to resolve the grievance, complaint or suggestion.

 

 

 

 

 

3. Describe how you would like to see this grievance, complaint or suggestion resolved:

 

 

 

 

Please complete this form and give it to your counselor or another staff member if you have a written grievance. Otherwise, please place this form in the Suggestion Box. The Palm Beach Institute considers client feedback very seriously, and will carefully review this form. As noted in the Client Grievance Procedure, a formal grievance process begins within 24 hours of your turning in this form.

 

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Client Signature                                 Date

 

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Client Name (Please Print)

 

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Staff Signature                                      Date/Time

 

Response to Grievance:

 

 

 

 

 

Copy Given to Patient On: ___________________ By: _________________________________

                                                  Date                                                   Staff Name