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Client Concern and Grievance Request
All clients/students have the right to informally and formally document concerns grievances. If the client/student is unable to fill out this form, due to disabilities such as unable to read or write, a staff member or advocate of their choice will give assistance to file a grievance.
Any questions regarding this form or grievances can be directed to Pastor Christina Hough, Director of Spiritual Care/Liaison at or at ext 1150.
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Email *
Client Name
Initiated By
Name/Relationship/Contact Information of Person Initiating
Type of Request
Submitted to (Name/Title)
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