Compliment / Complaint Form

Step Forward welcomes client feedback about interactions, appointments and services. Feedback gathered is used to continually improve how we provide services.

Please note that feedback will not be accepted as a request for service. Requests for service must originate with an agency program or service.

Which program or service are you providing feedback for today?*

Full Name (If current Client use Name as it appears in our records)*

Phone Number*

Please enter a valid phone number.

Phone Type*

Email*

example@example.com

Incident Date*

Date

Location of Incident*

Type of Interaction

In PersonBy Telephone

Did you have the same problem at a different site?

NOYES

Location of 2nd Incident

If your feedback involves a person (staff or other customer) and you know the name of that person enter here:

FEEDBACK TYPE (Check ALL that Apply)*

Please tell us exactly what happened?*

Discrimination or Violation of Privacy Complaint:

Step Forward operates in compliance with the Rights of Persons Served and will investigate any customer complaint of discrimination or violation of privacy in accordance with agency policy. However, in order for us to investigate or review your concerns, we must receive your complaint in writing and your letter of complaint must be signed. Incomplete information or an unsigned letter will delay the processing of your complaint.

Information needed to submit a formal complaint:

Please include the following information in your written letter of complaint to help us address your concerns as quickly as possible.
Client name, address, phone number, and email address
Program or service provided or being provided
If a single occurrence, date of incident; otherwise, please indicate date issue started
Please indicate which location the service was or is being provided. If services were not in person, list location as "by phone" or "remote"
Detailed explanation of the issue including events in the order in which they occurred, names of individuals involved, and any other information that will enable us to thoroughly understand your concerns
Please provide COPIES (do not send original documents) of all pertinent documentation relevant to your complaint
Please describe the resolution you seek.

Please mail your formal complaint to us. If you would like a delivery receipt, please bring your complaint in person during normal business hours or mail as a certified letter.

Step Forward
C/O Compliance Officer
Discrimination or Violation of Privacy Complaint
1801 Superior Avenue, 4th Floor
Cleveland, Ohio 44114

Please verify that you are human*

Feedback Form

FEEDBACK DETAILS

Discrimination or Violation of Privacy Complaint: