Grievance Form

Instructions

Please answer the following questions in order for us to best assist you.

All grievances are investigated. You have the right to remain anonymous when filing a grievance. Please note that if you choose to remain anonymous, Lionrock Recovery will not be able to respond to your request and/or grievance regarding its resolution.

Instructions

Please answer the following questions in order for us to best assist you.

All grievances are investigated. You have the right to remain anonymous when filing a grievance. Please note that if you choose to remain anonymous, Lionrock Recovery will not be able to respond to your request and/or grievance regarding its resolution.

Today's Date *

MM

/

DD

/

YYYY

First Name

Last Name

Date of Birth

MM

/

DD

/

YYYY

State You Reside

Phone Number

Best time to reach you

Morning

Afternoon

Evening

Clear selection

1. Describe the reason/reasons for filing a grievance. Be specific by including the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved. *

2. Have you tried to resolve the problem(s) before filing a grievance? *

Yes.

No. I have not made any prior attempt to resolve the problem(s).

Required

2a. If answered yes to question # 2, please describe what you have done to try to resolve the problem and include the results.

3. What would you like to happen to resolve the grievance? *

Please note the following:

For anonymous submissions, Lionrock will not be able to respond in writing; however, each grievance/complaint is investigated.

All other requests will receive a response within 5 working days. If you are not satisfied with the response or the plan to resolve the grievance, you have the right to file a notice of dissatisfaction. A meeting may be arranged between you and the appropriate staff. This meeting will occur within another five (5) working days following the notice of dissatisfaction.

You also have the right to contact the Joint Commission or the alcohol/drug/behavioral health regulatory agency within your state, regarding client complaints and grievances.