What do you believe would best resolve the situation or conflict, for yourself, or for others? *

If yes, who is (are) the staff person(s) involved?

Phone

Name

When did this incident happen? *

Is this regarding an interaction with a staff member of the IM SAFE CAC *

Yes

I'm not sure

Is this regarding a policy or practice of the IM SAFE CAC *

Yes

I'm not sure

Client Grievance Process & Reporting Form

Please select the statement that most closely describes the current conflict, issue, or incident.

I feel that I have been discriminated against, by staff, or by service policy, based on my race, citizenship/status, color, religion, sex, gender, national origin, age, orientation/ attraction, disability, political affiliation, or beliefs.

This issue is not related to discrimination, but I feel that I have not been treated with dignity, fairness, respect, and/ or professionalism

The IM SAFE CAC seeks to treat all clients with dignity, fairness, respect, and professionalism as we strive for excellence in providing services to clients. Our policy provides clients, and their families or legal guardians, with the opportunity to express any issues or grievances related to the quality of services provided. If you feel you have been treated unfairly, or unprofessionally, or feel that your rights have been breached, please complete the form below to inform the IM SAFE CAC staff and leadership.

The following options are available to you in the event of any service issues/conflict:

• If you are dissatisfied with IM SAFE CAC services, you can discuss the issue directly with your staff.
• If you are not satisfied with the solution reached after speaking with our staff about your concerns, if you feel that you have not been heard, or if you are not comfortable talking directly with our staff, you can:

1. Contact our Program Director Lisa Cloman directly at lcloman@imsafecac.org, (616) 225-7267.

2. Complete the form below to file a formal grievance. This grievance will be reviewed by our Program Director Lisa Cloman at lcloman@imsafecac.org, (616) 225-7267. You may remain anonymous or include your contact information to receive follow-up on what actions are taken to resolve the issue or complaint.

3. Write and submit a printed version of the grievance to the IM SAFE CAC personally or by mail to 10260 S Sheridan Road, Fenwick, MI 48834. This form can be downloaded below or completed in person during your appointment. Ask a staff person for a form if needed.

No individual, organization, or agency, may discharge or retaliate in any manner against any person that has filed a complaint or grievance.

Tell us about what has happened, and how it impacted you. *