CLIENT GRIEVANCE FORM

 

 

I, __________________________________, am filing this grievance with the Disability Law Center for the following reasons.  (Please complete sentences 1, 2, or 4, whichever applies to your grievance.)

 

  1.  I was denied services by DLC.  Explain:

 

 

  1. I am dissatisfied with the services that I am receiving.  Explain:

 

 

  1.  I am dissatisfied that my case was closed and that I have been denied further services.  Explain:

 

 

  1. I receive mental health services, or I am writing on behalf of one or more such individuals, and I have concerns about whether DLC is complying with legal requirements.  Explain. 

 

 

 

 

Signature: ____________________________________

 

Address: _____________________________________

 

              _____________________________________

 

Phone #: __(_______)___________________________

 

Mail Completed form to:

 

Disability Law Center

11 Beacon Street, Suite 925

Boston, MA 02108