Services Complaint & Concern Form

Use this Form to enter a formal complaint regarding concerns over services or treatment from BHN Programs.

These concerns can be entered on another person's behalf.

We aspire to be a community that is constantly learning from one another and our broader environment, and remain open to opportunities to improve and grow.

Date of Incident

If this is an ongoing issue, please supply the first date it was noted.

mm/dd/yyyy

Name of the person completing this Form:

Telephone Number

List the best number to contact you for follow up to this concern.

Phone

Supply an Email Address for updates on this Complaint.

_________________________________________________________________________

If known, the person(s) who has been impacted:

This can be self, a person-served, or a group of persons receiving services

Name of person(s) complaint is against:

Enter in "Unknown" if you don't know the name.

Program involved in this concern:

Enter in "Unknown" if if you don't know the name or program is not listed.

Please add name into Location below if not present on list.

Location of the Program or where the incident occurred:

_________________________________________________________________________

Please describe the issue or concern to the best of your knowledge

Provide examples, quotes, specific words used during the incident to help explain what occurred.

_______________________________________________________________________

Indicate if there are other sources of information about this concern that we should be aware of, such as:

Emails
Text messages
Screenshots
Camera footage

List any BHN Management who are aware of the issue:

If you know their names or titles.

Please attach any relevant files

These can be Word doc, PDFs, emails, pictures.

Drop your files here

*Submitted forms will be reviewed within 72 hours of receipt

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