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Children's Community Mental Health Services
& Wraparound Milwaukee

One Child, One Plan for Youth up to Age 23

Family running towards sun

Grievance Form

Please note that this form is ONLY for grievances related to Children's Community Mental Health Services and Wraparound Milwaukee (Wraparound, REACH, CCS, CORE, FISS).

To be completed by any individual (such as a youth, parent/guardian, other family member, provider, etc.) who would like to file a grievance or appeal. If you need any assistance to complete the form, please contact: Client Rights Specialist at (414) 257-7600, option 1.

Today's Date: 

Name of Person/Agency filing Grievance/Appeal:

Check your association with our program:Youth/Enrollee Parent/Guardian Other family member Provider 

Street Address, City, State, Zip Code (of person filing grievance/appeal): 

Phone number (of person filing grievance/appeal): 

Name of associated Youth/Enrollee: 

If a grievance, list the name of Person/Agency the grievance is against: 

A. Please describe your grievance or appeal. Include details, such as dates, times and individuals involved.

B. If this is a grievance, what have you done in an attempt to resolve the issue (i.e. discuss with the Provider, Care Coordinator, Supervision, and/or Child & Family Team, etc.). Please explain.

C. What would you like to see happen about this grievance/appeal? How would you like the issue resolved?

D. Any additional information?

Please check this box to confirm your electronic signature

Name:  Date: 

 

MILWAUKEE COUNTY DEPARTMENT OF HEALTH & HUMAN SERVICES

1220 W. Vliet St.

Suite 301

Milwaukee, Wisconsin 53205

Our Vision

Together, creating healthy communities.

Our Mission

Empowering safe, healthy, meaningful lives.

Our Values

Partnership, Respect, Integrity, 

Diversity, Excellence

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