Client Portal

Client Grievance

A form for clients to report issues with SAFE Center services

Instructions:

1. Please use this form to tell us about your experience and concerns.
2. Please write clearly so that we may address your concerns in a timely manner.
3. Please provide us with your phone number and email so that we may contact you.

Your Name

First Last

Date

Your Phone Number

Name of staff member involved in the grievance

Please describe your concerns.

Have you been able to discuss your concerns with staff? If yes, what was their response?

What would you like the outcome of your concerns to be?

Do you have any other comments or concerns?

Client Grievance

Instructions:

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