Grievance Form

This form is designed for use when attempts to resolve concerns with the primary service provider, supervisor, and/or manager have been unsuccessful. Youth and families are encouraged to discuss their concerns with the service team prior to filing a grievance. Clients Rights Officer: David Phinney Email: clientsrightsofficer@buckeyeranch.org Phone (Voicemail Only): (614) 539-6426 **Note: The only way to initiate the grievance process is by submitting this form**

Date Date / MM / DD YYYY
Name Name First Last
Phone Phone - ### - ### ####
Address Address
Street Address City State / Province / Region Postal / Zip Code
Program

Program Bonner Academy (Day Treatment) CME (Care Coordination) Community Based Mental Health (IFSP, IHBT, ICT, MST, FFT, Outpatient) Foster Care/Adoption Permanent Family Solutions Network (PFSN) Residential (PRTF, QRTP) School Based Mental Health Services Somali Outreach and Mental Health
Have you notified your primary provider/worker's supervisor of your concerns?

Have you notified your primary provider/worker's supervisor of your concerns? Yes No
If yes, whom did you contact? If yes, whom did you contact? First Last
On what date was this contact made or attempted? On what date was this contact made or attempted? / MM / DD YYYY
Please state your grievance below:
By submitting this form, I acknowledge that I have reviewed and understand the Grievance Procedure and Clients Rights and I am willfully submitting this form.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.