ALL COMMUNITIES OUTREACH SERVICES

ALL COMMUNITIES OUTREACH CLIENT GRIEVANCE FORM 

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Please note, if you prefer, you can submit your grievance to the confidential ACOS Client Grievance Voicemail box at 402-257-1122 ext 806. Please be sure to include a complete description of the incident and your contact information.

Client Name: ______________________________________________________________________

Address and Phone number (if you wish to be contacted): ______________________________________

_____________________________________________________________________________________

Parent/Guardian’s Name:________________________________________________________________________________

Today’s Date:__________________________ Time of Grievance, if known_________________________

Name(s) of All Community Outreach Service Staff Involved:_____________________________________

_____________________________________________________________________________________

Type of Grievance: O Facility/Environment, O Fee/Payment Issues, O Privacy Rights/Confidentiality

O Treatment/Quality of Care, O Other:_____________________________________

Where did the incident occur?____________________________________________________________

Briefly describe the incident or nature of grievance____________________________________________

__________________________________________________________________________________________________________________________________________________________________________

What would you like to see done to resolve this incident or grievance?____________________________

__________________________________________________________________________________________________________________________________________________________________________

What attempts have you already made to resolve this incident or grievance?_______________________

__________________________________________________________________________________________________________________________________________________________________________

Client Signature: ________________________________ Date:__________________________________

If Returning by Mail, Please send to:

Director Of Quality Improvement

All Communities Outreach Service

112 E. Mission Ave

Bellevue, NE 68005