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.
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