Concerns or Complaints. If you are dissatisfied with the services received, you are encouraged to discuss your concerns with your healthcare professional. Your provider will take your concerns seriously and will treat you with care and respect. If you are not satisfied with the resolution, you can contact the California Board of Psychology of the Department of Consumer Affairs at 0000 Xxxx Xxxxxx, Suite 22, Sacramento, California 00000-0000. Or you may reach them at 000-000-0000. By signing below, you acknowledge that you have read and understand the above policies and procedures, and agree to abide by them. Name Name Signature Signature Date Date The Clinic 000 Xxxx Xxxxxx, #368 San Francisco, CA 94117 xxx.xxxxxxxxxxx.xxx PH 000-000-0000
Concerns or Complaints. 11.3.1 If you have any concerns or complaints about any issue concerning your child’s welfare at the School, please come and talk to us - we have an open door policy. Should you wish to proceed with a more formal complaint, please refer to the complaints policy on the internet which is also available in hard copy format.
Concerns or Complaints. The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the Colorado State Department of Regulatory Agencies. Any questions, concerns, or complaints regarding the practice of mental health may be directed to the State Board: Mental Health Section of the Colorado State Grievance Board, 0000 Xxxxxxxx, Xxxxx 0000, Xxxxxx, Xxxxxxxx, 00000, (000) 000-0000. You are entitled to receive information at any time about my methods of therapy, the techniques I use, the expected duration of your therapy, and my fee structure. You may seek a second opinion from another therapist or may terminate therapy at any time. Dual roles, exploitative relationships and sexual intimacy are never appropriate in a professional relationship and should be reported to the Grievance Board. Sexual intimacy is also illegal and should be reported to the State Grievance Board at the address and phone number listed above. If you should need additional information or clarification about any of the information covered in this disclosure document, please feel free to ask me now or at any time in the future. Your signature indicates that you have read the above information, have had the opportunity to ask questions and understand your rights as a client. By signing this disclosure statement, you understand and agree to all of the terms discussed above. MY SIGNATURE BELOW INDICATES THAT I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. Signature Date Printed Name Client name (if different) Xxxxx Xxxxx, LCSW Arts and Insights, LLC NAME: DATE OF BIRTH: AGE: ADDRESS: PHONE NUMBER (home): PHONE NUMBER (work): PHONE NUMBER (mobile): EMAIL: Best way to reach you (circle one): home cell work email Referral Source: Friend/relative Previous client Internet search Psychology Today Insurance EAP (specify) other (specify) Employment: Full Time Part Time Self Employed Student Marital Status: Single Married (#years) (#years) Widowed (# years) Divorced (years) Living as Married (# years) Separated Emergency Contact Information Name: Phone: Relationship to you: Primary Care Physician phone: Please check the items you would like to address in therapy (adults, teens, children):
Concerns or Complaints. 5.1 Any concerns or complaints of the Occupant in relation to the Room, any other part of the Citywest Suites building, the utilities and / or services provided within the Room or any other matter should be brought to the attention of CBA or any of its servants or agents as soon as practicable. I have read and fully understand and further agree to observe the terms and conditions of this Licence and to procure that any Additional Occupiers approved by CBA observe the terms and conditions of this Licence. I understand that failure to pay the occupancy charge or to observe the terms and conditions of this Licence may result in termination in accordance with the provisions of this Licence. CBA hereby agrees to be observe and be bound by the terms and conditions of this Licence. Date Signed by the Occupant Date
Concerns or Complaints. Every endeavour will be made to try to resolve any issues that may arise. However, if any matter is not dealt with to your satisfaction your complaint should be made in writing to our complaints manager, Xxxxxx Xxxx, at xxxxxxxxxx@xxxxxxx.xx.xxx and the matter will be reviewed and responded to promptly. We will acknowledge your concern or complaint within three working days and promptly investigate the matter. We may request further information from you to enable us to do this. We will endeavour to provide you with our final outcome within four weeks of receipt of your initial correspondence, unless further information is requested from you or other parties. In the event that we are unable to provide you with a final response within this timeframe, we will advise you of this within the four week period and a final response will be provided to you within eight weeks of receipt of the initial complaint. If your concern or complaint is in relation to a formal insolvency procedure and in the event that you are still not satisfied and wish to take the matter further, your complaint will be passed to our external compliance and monitoring consultants for them to review the matter independently. We will report the outcome of any independent investigation to you within two weeks of receiving it ourselves. Should you remain dissatisfied, you may make a complaint to through the Government’s Insolvency Service Complaints Gateway who will review it and, if appropriate, forward it to our regulatory body for further investigation. This is the gateway through which all formal complaints against insolvency practitioners must be made: Website: xxx.xxx.xx/xxxxxxxx-xxxxx-xxxxxxxxxx-xxxxxxxxxxxx E-mail: xx.xxxxxxxxxx@xxxxxxxxxx.xxx.xxx.xx Post: The Insolvency Service, IP Complaints, 3rd Floor, 0 Xxxx Xxxx, Xxxxx, XX00 0XX Tel: 0000 000 0000 – calls are charged at between 1p and 10.5p per minute from a landline; for mobiles, between 12p and 41p per minute if you are calling from the UK. If your concern or complaint is in relation to probate or estate administration and in the event that you are still not satisfied and wish to take the matter further, your complaint will be passed to our external compliance and monitoring consultants for them to review the matter independently. We will report the outcome of any independent investigation to you within two weeks of receiving it ourselves. Should you remain dissatisfied, you will usually have 6 months of receiving our final writte...
Concerns or Complaints. If you are dissatisfied with the services received, you are encouraged to discuss your concerns with your doctor. Your doctor will take your concerns seriously and will treat you with care and respect. If you are not satisfied with the resolution, you can contact The Medical Board of California at 000-000-0000. You may also reach the Medical Board of California - Central Complaint Unit 0000 Xxxxxxxxx Xx. Xxxxx 0000 Xxxxxxxxxx, XX 00000. If you are in New York, you can contact the Office of Professional Medical Conduct, NYS Department of Health, Riverview Center 000 Xxxxxxxx, Xxxxx 000 Xxxxxx, Xxx York 00000-0000. Phone: 000-000-0000 or 0-000-000-0000. By signing below, you acknowledge that you have read and understand the above policies and procedures. Name Name Signature Signature
Concerns or Complaints. In the event of there being cause for concern or complaint about a Room/Apartment, the Owner encourages Guests to take up the matter with them at once, ideally while they are still at Harrabeer Country House so they can respond immediately.
Concerns or Complaints. If for any reason you are not satisfied with the service you receive, we need to know. Please ask for more details of our complaint procedure. Alternatively, you can send an email to xxxxxxxxxxxxxxx@xxxx.xxx.xx, where a member of the CABB Executive Team, will look into your feedback and make contact with you directly. Client signature confirming understanding of this document: Date:
