Client Grievances Survey Thank you for taking the time to share a concern or grievance.Your feedback helps us improve our services.Sharing a concern will not affect your services or treatment in any way.You may skip any question and may complete this form with the support of a trusted family member, advocate, or representative if you choose. Question Title * 1. Name Question Title * 2. Phone Question Title * 3. Email About the Concern Question Title * 4. What type of service or interaction was involved? Individual Counseling Group Counseling Medication / Nursing Case Management / Peer Support Front Desk / Scheduling Intake / Initial Assessment Prefer not to say Other (please specify) Description of the Incident Question Title * 5. When did the incident occur? Date / Time Date Time AM/PM - AM PM Question Title * 6. Where did the incident occur? New Brunswick Counseling Center (NBCC) Burlington Comprehensive Counseling (BCC) Telehealth (NBCC) Telehealth (BCC) Middlesex County Mobile Unit (NBCC-Renew) Burlington County Mobile Unit (NBCC-Renew) Prefer not to say Other (please specify) Question Title * 7. Who was involved in or witnessed the incident? Counselor / Clinician Nurse / Medical staff Case manager / Peer Front desk staff Security Another client / patient Not comfortable sharing Other (please specify) Question Title * 8. In your own words, tell us about your concern (ex. who, what, when, where the event took place). Share as much or as little detail as you feel comfortable with. Question Title * 9. What outcome are you hoping for in regard to your grievance? Question Title * 10. Is there anything else you would like us to know? Note: Survey responses are not monitored for emergencies.For urgent safety issues, call 911 or 988. Done
