ARCC Center Parent/Guardian Concern Form// ARCC Center
Thank you very much for taking the time to fill out this information, this will help us to address your concern as soon as possible! An ARCC Center Supervisor will review and investigate your concern ASAP.
Client Full Name
Parent Full Name
Parent Contact Number
SDRC Service Coordinator Name
Date of Incident
Please check the box if the incident happened on more than one occasion
Please check the box or boxes that fits with your concern today
No call/no show
Last minute cancellation
Would like a new Respite Worker
Respite Worker is not available for my schedule
Incident during session
Sibling hours issue
Pick up or drop off issue
Clock in/out issue
Respite Worker on cell phone
Communication issue (Respite Worker is not replying to you)
Response to behaviors
Please explain in detail your concern. Please include dates (if you have them) and names
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This form was created inside of Autism, Respite, Camp, & Childcare Center, LLC.