ARAPAHOE HOUSE
FEEDBACK & GRIEVANCE FORM
Completing this form:
In order to effectively address your feedback or concerns, we find it helpful to have all questions answered as thoroughly as possible. Thank you for tkaing the time to participate in our Feedback and Grievance System!
1. This feedback is in reference to:
Access to treatment
Accessing files, records
Compliment
Customer Service
Facility conditions (cleanliness, safety of buildings, etc.)
Fees
Food
Medications
Missing Property/Money
Other clients
Privacy, Confidentiality, HIPAA
Rules and procedures
Service quality and appropriateness
Staff actions
Other:
2. Please identify the program or location this feedback concerns:
3. Please describe your feedback or concern:
4. If reporting a problem, what do you suggest as a solution?
5.a. If it is acceptable to contact you, what method do you prefer?
Email
Phone
Mail
I don't want to be contacted
5.b. Is it acceptable for Arapahoe House to leave a message (identifying who we are and why we are calling) on your voice mail, email, or with a person answering the phone? (Check all that apply.)
No
E-mail - Yes
Phone - Yes
Person - Yes
6. In order to contact you and effectively address your feedback, we find it very helpful to have your name and contact information; however,
providing this information is optional.
Your full name (first, last):
Your Arapahoe House Client ID#:
Your email address:
Your daytime phone number:
Your mailing address:
7. I am:
Attempting to enter treatment at Arapahoe House (AH)
A current or past client of AH
Family member/friend of someone who is/was a client at AH
Family member/friend of someone who is/was seeking services at AH
Representative of an agency referring someone into services at AH
Other (please describe)
8. If this feedback concerns a client or someone seeking treatment, is the individual an:
Adolescent (Younger than 18 years)
Adult (18 years of age or older)
Unknown
Not applicable
9. If you are reporting on behalf of another Arapahoe House client having their name would be very helpful to us; however,
disclosing this person's name is optional
.
Client first name:
Client last name:
Client's AH ID: (if known)
Notice: Information provided on this page will be emailed to Arapahoe House, Inc.
for follow-up. While very unlikely, it is possible the information could be
intercepted or received by someone other than the intended recipient. If you
are uncomfortable submitting information on this page, please contact us
by telephone at 303-412-3696 to submit your feedback. Thank you.