Client Grievance Report

Client Grievance Report
Point of Contact Information

This is the information of the person completing this form
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Please select One: *

I am an administration member of Family Service of El Paso I am a Clinician at Family Service of El Paso I am a Client I am a third party
Please select the party of which you are completing this form about: *

A Family Service of El Paso employee A Clinician at Family Service of El Paso A Client A third party
Clinician Information *

First Name Last Name
Clinician Email
example@example.com
Employee Information
Employee Name

First Name Last Name
Client Information
Client Name *

First Name Last Name
Client Birth Date *

Month Day Year
Clients Email *
example@example.com
Third Party Information *

First Name Last Name
Third Party Email
example@example.com
Provide a brief explanation of your grievance
Please provide as much information possible that could help resolve this grievance *
Should be Empty:

Employee Information