FH-CL-009 • VERSION 1.0

Client Complaint & Grievance Form

Concerns, safety triage, requested resolution and follow-up.

Digital workflow: Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.

1. Record identification

Client name *

Date *

Completed by *

Person making complaint / relationship / contact

Incident date, time and location

Concern category

People involved / witnesses

What happened and what was expected *

Immediate danger? *

Abuse, neglect, exploitation, theft, violence or sexual misconduct concern?

Prior report and outcome

Supporting information

Requested resolution

Triage priority

External report / reference number

Investigation and findings

Resolution / response / status

Electronic signature / typed name *

Signature date *

Notes