Feedback and Grievance Form

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

If it is acceptable to contact you, what method do you prefer?:

Email

Phone

Mail

I don’t want to be contacted

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

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 below)

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

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