Complaints & Grievances

Please complete this form to file a formal complaint or grievance.

If you need assistance filling out this form, please contact a staff member or the Grievance Officer.

Name of Person Filing Complaint

First Last

Relationship to Individual Receiving Services

Phone

Email

Name of Individual Receiving Services(Required)

First Last

Program / Service Involved

Date of Incident

(if applicable)

Location of Incident

Description of Complaint or Grievance(Required)

Please describe the situation, who was involved, and what occurred.

Have you discussed this with anyone at the agency?(Required)

YES

NO

Who did you discuss this with, and what was the outcome?(Required)

What would you like to see happen to resolve this issue?

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

151 N 8th St
Suite 350
Lincoln, NE 68508