Contact Us


    Report a Grievance


    Complete this form if you'd like to report an issue or complaint.

    Please allow 48 hours for processing.


    Your First & Last Name

    Phone Number
    () -  - 

    Email (optional)

    Mailing Address (optional)

    Managing Party Name

    Individual Receiving Services


    Remedy Sought

    Briefly describe what you want to happen. What will resolve your grievance?

    Issue and People Involved

    Date of Incident
     [None] Select a Date Delete the Date

    People Involved 

    Description of Issue

    Actions to Remedy

    Briefly describe what actions you have taken to resolve the issue.