Detroit Continuum of CareClient Complaint/Grievance Form

Detroit Continuum of Care

Client Complaint/Grievance Form

If you have a complaint/grievance that you would like to file regarding the Detroit Continuum of Care and/or a specific provider, please complete the following form. The complaint/grievance will be investigated, and a response will be provided within 20 business days of the committee’s decision. Please Note: If this grievance is against a shelter, the shelter funder will be contacted to complete the investigation.

Name of Person Making Complaint:

DOB:

HMIS Number (If available):

Please use the space below to provide information about your complaint.

Please list BOTH the agency name and the specific program your grievance is against. If you do not know the program name, but know the program type (e.g. Permanent Housing, Shelter, etc.), please list that.

Agency:

Program:

Date of Complaint:

Date of Event(s):

Have you filed a grievance directly with the agency already?

**Note: If you have not taken action with the agency, please do so before pursuing this process at the CoC Level. A link to the grievance policy can be found on HAND’s website (handetroit.org).**

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What was the outcome of the action you’ve taken directly with the agency?

What action do you feel the agency should have taken?

Statement of Complaint

Please provide details of the situation and complaint including any of the specific dates of occurrence as well as the agencies, programs and/or staff involved.

Desired Resolution/Response

What would you like to happen as a result of your complaint?

Do you have a case manager or another support person that you would like us to contact

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If yes, name and phone number:

Where are you staying currently? Are you still in the program your grievance is against?

Contact Information

Please provide your contact information so that we can follow up with you – in case we have additional questions and to inform you of the final determination.

Primary Phone Number (if available):

Email Address (if available):

Secondary Phone Number (if available):

Address (if available):

What is the best method to contact you?

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If other, please specify?

May we share this grievance form with the agency your complaint is against?

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E-Signature of Person Making Complaint:*

File Upload

Drag and drop files here or

Send me a copy of my responses

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