Client Complaint_Grievance | Davis Behavioral Health.NET

Client Name: *

Client ID:

Client Phone Number: *

Title 19 ID:

Indicate Whether Client has Non-Traditional Plan *

Yes No

Person Making Complaint: *

Relationship to Client / Agency: *

Phone Number of Person Making Complaint *

Person Receiving Complaint: *

Date of Complaint *

Indicate the Type of Complaint *

Verbal Written (give written complaints to the corporate compliance officer)

Indicate the Type of Response *

Verbal Written (give copy to corporate compliance officer) Letter sent (give copy to corporate compliance officer) Still trying to contact complainant Unable to contact complainant

Nature of the Complaint / Concern: *

Action Taken by The Person Who Received the Complaint: *

Complaint Resolution *

Resolution Reported to: *

Actions Suggested to Follow-Up: *

None See description below

Actions Suggested to Follow-Up *