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(Rev. 09/13/11 by WLF) CORTLAND COUNTY MENTAL HEALTH DEPARTMENT CLIENT GRIEVANCE FORM 1. Please list, in as much detail as possible, your concern or complaint. [Use the back of this form or attach additional sheets as necessary.] 2. What would you like to see happen to resolve this problem? 3. Have you discussed your concern or complaint with anyone at the clinic? If so, who did you discuss your concern or complaint? 4. What was the response to your concern or complaint? [Please attach a copy of any written response you have received regarding your concern or complaint.] Name Date Address Telephone # What is the best way to contact FOR INTERNAL USE ONLY Received by: Date: Forwarded to: Date: UPON FINAL RESOLUTION OF THE WRITTEN COMPLAINT, THE WRITTEN COMPLAINT AND ALL WRITTEN RESOLUTIONS MUST BE TURNED INTO THE COMPLIANCE OFFICER.