Grievance Form

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 ACTS employee and would like to file a grievance about a specific issue, please complete the grievance form on the ACTS Intranet.

Client Grievance Form

"*" indicates required fields

Date*

Name*

First Last

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Most recent program*

What else would you like to tell us?*

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?*

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

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

ACTS Quality Improvement
3450 Buschwood Park Drive
Suite 345
Tampa, FL 33618
Phone: (813) 246-4899
Fax: (813) 367-0186

Download our Grievance Form

Title VI Complaint Form