Ascent Client Rights Complaint Form
This form is in compliance with Ohio Administrative Code 5122-26-18 Client Rights and Grievance Procedure.
Today's Date *
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Name of Client/Peer
First & Last Name
Your answer
Name of Person Filing Grievance/Complaint:
You are welcome to remain anonymous.
Your answer
Relationship to Client/Peer (if not the person filing)
Your answer
Address, City, State, Zip *
This is so that we may mail you a copy of your complaint and findings following the investigation.
Your answer
Best phone # to reach you?
Your answer
Best email to reach you?
Your answer
Date When Incident Occurred *
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Brief Summary of Incident: *
Please explain the incident in question.
Your answer
Person(s) or Staff(s) Involved *
Please list any/all person/staff involved in incident
Your answer
Describe what actions you have taken to resolve the concern. Include staff contact and contact with others involved. *
Your answer
What is your desired outcome?
Your answer
What action do you want Ascent to take?
Your answer
By typing your name below, you are stating that all information above is accurate to the best of your understanding. *
Please type your full name below.
Your answer
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