Client Grievance Form
In accordance with our Client Grievance Policy, all persons receiving services, directly or
indirectly, from DHHSC, have the right to file a grievance for unsatisfactory services
rendered. In an effort to address and respond to your specific concern, please complete
the following information as thoroughly as possible.
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Your name *
Address *
Phone number *
Date Grievance form filled out *
MM
/
DD
/
YYYY
Have you read and understand our Grievance Form Policy? *
To which staff member is your grievance against? *
Have you attempted to address your grievance with the above named DHHSC staff? *
Please explain in as much detail as possible the reason for your grievance? *
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