Department Of Mental Health Complaint Form
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1
2104 CMR 32.00
For Department Use Only
DEPARTMENT OF MENTAL HEALTH
Date Received: ____/___/_____
COMPLAINT FORM
Received By: _____________________
Log #: ___________________________
*
1.
NAME OF COMPLAINANT(S)
STATUS
ADDRESS AND TELEPHONE # (OR PROGRAM NAME)
a.
b.
c.
2.
Client(s)Thought to be Harmed by Matter Complained of (if
ADDRESS AND TELEPHONE # (OR PROGRAM NAME)
any and if known)
a.
b.
c.
3.
NAME(S) OF PERSON(S) COMPLAINED OF
STATUS*
ADDRESS AND TELEPHONE # (OR PROGRAM NAME)
(if any and if known)
c.
4.
PERSON FILLING OUT FORM (if other than above):
5.
WHEN DID MATTER COMPLAINED OF OCCUR [Date(s) and Time(s)]?
6.
WHERE DID MATTER COMPLAINED OF OCCUR?
7.
Describe what Happened (Continue on back and/or attach additional sheets as necessary):
7.
What Happened (Continued):
*
STATUS: C=Client; E=Employee; H=Human Rights Committee; R=Relative; O=Other (Specify)
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