CLIENT GRIEVANCE FORM

ACTS Grievance Form

Phone Number: *

Date *

Briefly describe your grievance. Where and when did it happen? Who was involved? *

What have you done to address your concern prior to filing a grievance and what happened? *

Title VI Complaint Form

Most recent program *

Name: *

If you are a client, former client, or an authorized designee, and have a specific issue you want brought to the attention of program management for investigation or if you believe you have experienced unjust, unethical, discriminatory or illegal treatment, please use this form to file a grievance.

Filing a grievance will not adversely affect the services you receive.
*This email is not continuously monitored and is not intended for crisis or emergency services.

**If you are a current or former ACTS employee and would like to file a grievance about a specific issue, click here for the “Employee Grievance Form”, so that your employee grievance is routed to the correct departments. To submit a Title VI Complaint, please fill out the form at the bottom of page.

Explain what you would like done to address and resolve your grievance?

Address: *

CLIENT GRIEVANCE FORM

You may also download a copy of our grievance form below and mail or fax it to:

ACTS Quality Improvement
4612 N. 56th St.
Tampa, FL 33610
Phone: (813) 246-4899
Fax: (813) 367-0186

CLIENT GRIEVANCE FORM

You may also download a copy of our grievance form below and mail or fax it to:

ACTS Quality Improvement4612 N. 56th St. Tampa, FL 33610Phone: (813) 246-4899​Fax: (813) 367-0186

ACTS Quality Improvement
4612 N. 56th St.
Tampa, FL 33610
Phone: (813) 246-4899
Fax: (813) 367-0186