Client Complaint Form

Name

Date

Remain Anonymous

Issue

Describe Situation

Where did the situation occur?

People involved, including witness(es)

Did you talk about this issue with the person involved?

If yes, what was the outcome?

What is the outcome you would like to see?

Home telephone number

Cell number

Home address:

Do you have additional comments at this time?

Captcha *

Champlain East Branch
329 Pitt Street
Cornwall , K6J 3R1, Ontario
1-800-493-8271
office@cmha-east.on.ca
Hours:
Monday to Friday 8:30am – 4:30pm