Grievance Procedure Staff Person Taking Report: Reporting Party: Contact Email: Contact Phone: Date: Time: Initial Contact Form: In Person Telephone Correspondence Other: Grieving Party: Address: Phone Number: Relationship: Recipient of Service Relative or Friend of Treatment Recipient Guardian of Treatment Recipient Mental Health Authority Other Provider: Description of Grievance (Please be as specific as possible.) What Happened? Who was Involved? (Include any witnesses to event) When did the incident take place? What was the resulting harm? Additional Comments Anti-Spam Code: If you can't read the code, click here.