Name *

First Name

Last Name

Phone Number *

(###)

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I prefer to be contacted by ... *

Phone

Email

Today's Date *

MM

DD

YYYY

When did the issue occur or, if recurring, when did it begin? *

MM

DD

YYYY

Which of these categories best describes your grievance? *

Please select at least one grievance category

In-Session Event

Out-of-Session Event

Clinical Concern (incl. licensure)

Billing

Administrative (incl. scheduling)

Other

Was this issue discussed with the named Therapist / Staff prior to submitting this form? *

Yes

No