Grievance Form

If you have any concerns about the care you or someone else is receiving with the staff at the Raices de Bienestar clinic, or there are other problems you have experienced with the organization, we welcome and appreciate your feedback. Please provide the following information so that we can investigate your concern and do our best to find a solution. We will respond to your request within 14 days, unless it needs to be an expedited request (see below).

Name

First Name

Last Name

Today’s date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

How would you like to be contacted?

Date of occurrence/incident

MM

DD

YYYY

Please describe your concern, and include the name of anyone working on our team that was involved:

Expedited Request.

Does this complaint involve an emergency that is likely to cause you or someone else harm? If so, describe what makes it an emergency that needs to be addressed immediately:

If this involved someone on our team, have you already shared your concern with that person?

Yes

No

Please share any ideas you have to resolve the issue: