Access to Services in Your Language: Complaint Form

OMH works diligently to ensure individuals and families with language access needs obtain quality mental health services and supports. Mental health service providers are required to provide language access services to people with Limited English Proficiency (LEP). This includes:
1) Providing mental health services in an individual's preferred language.
2) Providing an interpreter if needed, at no charge.

3) Providing vital forms and documents in an individual’s preferred language.
If you feel that you did not receive services in your preferred language, please complete the following information. If you should have any additional questions, please reach out to matthew.canuteson@omh.ny.gov.

Question Title

* 1. Person making the complaint:

First Name:

Last Name:

Street Address:

City, Town or Village:

State:

Zip Code:

Preferred Language:

E-Mail Address (if available):

Phone Number:

If someone else assisted you in completing this form, what is their name?

Question Title

* 2. What was the problem? Check all the boxes that apply and explain below.

I was not offered an interpreter

I asked for an interpreter and was denied

The interpreter(s) or translator(s) skills were not good (List their names below, if known)

The interpreter(s) made rude or inappropriate comments

The services took too long

I was not given forms or notices in a language I can understand

I was unable to use services, programs or activities

Other (please specify)

Question Title

* 3. When did the problem occur?

Date (mm/dd/yyyy):

Time:

Question Title

* 4. Where did the problem occur?

Question Title

* 5. Describe what happened. Please be specific. List language, services and
documents needed. Include names, addresses and phone numbers of people involved, if known.

Access to Services in Your Language: Complaint Form

Question Title

* 1. Person making the complaint:

Question Title

* 2. What was the problem? Check all the boxes that apply and explain below.

Question Title

* 3. When did the problem occur?

Question Title

* 4. Where did the problem occur?

Question Title

* 5. Describe what happened. Please be specific. List language, services anddocuments needed. Include names, addresses and phone numbers of people involved, if known.

Question Title

* 6. Did you complain to anyone from the Department/Agency? Who and what was the response? Please be specific.

* 5. Describe what happened. Please be specific. List language, services and
documents needed. Include names, addresses and phone numbers of people involved, if known.