(MHC) – Client Grievance Form

Description of Grievance

(Please describe the issue in detail. Attach additional pages if necessary)
Please describe the issue in detail Attach additional pages if necessary
Initial Reporting:
Reporting Via:

Other
Name of Staff Representative:
Date Reported:

MonthDayYear
Date

Requested Resolution

(What outcome are you seeking?)
What outcome are you seeking?
Eligibility Acknowledgement By signing below, I confirm that:
- I am directly involved in the issue described above.
- This grievance does not involve fund allocation matters.
- The information provided is accurate to the best of my knowledge.
(Aligned with grievance parameters in your policy)
I acknowledge that I have read and understand the grievance procedure and that my concern will be reviewed in accordance with MHC policies.

Clear
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Client Information