ICCS Client Concern and Complaint Form

Who is this Form for?

This form is for clients and program participants of ICCS to express concerns and complaints about any aspect of your participation in a program. See our Feedback Page for other ways to respond.

Need help filling in this form? A support worker or case worker will be happy to assist you. If you are someone assisting with this form, please leave your details below where indicated.

If you are experiencing severe symptoms and need an appointment with a nurse, doctor, or counsellor, etc., or if you have medical needs (including mental health needs) that this program can not meet, please speak immediately with a staff member who can help, call the crisis line at 1‑888‑494‑3888, or 911

Not a client?

If you are an employee or community member, please see our Feedback Page for other ways to share your feedback.

Name - we appreciate knowing who has provided feedback, but your name is optional

First Last

Name

Which program or service does this relate to?(Required)

Please provide details below about your concern or complaint:(Required)

Have you talked with someone about your concerns?(Required)

Yes

Unsure

Who did you speak to?

How would you like us to resolve it?

How would you like us to contact you if needed? (phone number, e-mail, etc.)

Is there anything you would like to add?

Did someone provide assistance with this form?

Yes

I'm submitting this form on behalf of the person named above. My name and relationship to the client is:

Leave this field blank if no-one assisted you.

Contact information for the person assisting with this form.

Leave blank if no-one assisted with this form.

Thank you for taking the time to let us know about your concern. We value feedback and take seriously all the complaints we receive. REMEMBER TO CLICK SUBMIT BELOW.

Phone

This field is for validation purposes and should be left unchanged.

ICCS Client Concern and Complaint Form

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