*Grievant First Name (Please enter your first name): *Grievant Last Name (Please enter your last name): *Grievant Phone Number (Please enter your phone number): *Grievant Email Address (Please enter your email address): *Grievant Relationship to Provider: Current Resident Current Staff Member Family Member of a Current Resident Former Resident Former Staff Member Family Member of a Former Resident Neighbor or Community Resident Therapist, Care Coordinator, or Case Manager Other (Please describe) Other: I claim direct, first-person knowledge related to this grievance.: *Provider Name (Facility against whom Grievance is being filed): Provider Street Address: *Provider City: *Provider State: Provider Zip Code: Provider Primary Contact: Provider Phone: *Grievant alleges Provider non-compliance with NARR Core Principles listed below. (Please select all that apply): Residence Operates with IntegrityResidence Upholds Resident RightsResidence is Recovery-OrientedResidence is Peer Staffed and GovernedResidence Promotes HealthResidence Provides a HomeResidence Inspires PurposeResidence Cultivates CommunityResidence Promotes RecoveryResidence Promotes SafetyResidence is a Good NeighborOther (describe in field below) Other: *Nature of Grievance (Please provide a detailed narrative explaining the nature of the grievance below): Supporting Documentation: *I certify that the above information is entirely accurate to the best of my knowledge:
