- CMHA Cochrane-Timiskaming

Complaint / Feedback Form

Date(Nécessaire)

Date of Incident

Name

Prénom Nom

What site did this occur at?(Nécessaire)

Have you spoken to staff about your complaint?

If yes, who:

Please provide a description of your complaint:(Nécessaire)

Affiliation to Complaint / CMHA-CT(Nécessaire)

Concerned Community Member

Client

Service Provider

Support Person

Other:

Program(Nécessaire)

Phone

Preferred Method of Contact:(Nécessaire)

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.)