- CMHA Cochrane-Timiskaming

Complaint / Feedback Form

Date(Required)

Date of Incident

Name

First Last

What site did this occur at?(Required)

Have you spoken to staff about your complaint?

If yes, who:

Please provide a description of your complaint:(Required)

Affiliation to Complaint / CMHA-CT(Required)

Concerned Community Member

Client

Service Provider

Support Person

Other:

Program(Required)

Phone

Preferred Method of Contact:(Required)

Can a message be left at the number provided?

Additional Information:

(Feel safe to share how and/or why this incident or these concerns impacted you or someone else.)