Complainant Information

I would like to complain anonymously

First Name
Last Name
Email Address
Daytime Phone
Alternate Phone
Address Line 1
Address Line 2
City
State	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip

Facility Information
Facility Name	Agency for Community Treatment Svcs Boley, Inc. C.E. Mendez Foundation Carlton Manor, Inc. Central Florida Behavioral Health Network Central Florida Behavioral Hospital Centre For Women Charlotte Behavioral Health Care Childrens Mental Health Coastal Behavioral Healthcare, Inc. DACCO Dade County HUD Inactive Dade Family Couseling CMHC, Inc. David Lawrence Center DCF Devereux Hospital and Children's Ctr. Directions For Mental Health Dr. Deborah Smith First Step of Sarasota, Inc. Florida Center Gulf Coast Jewish Family Services, Inc H.S.A. Healthy Start Coalition Hendry-Glades M. H. Clinic, Inc. Human Services Associates, Inc. Inter Act Alliance K.C. Guardian Lee Mental Health Center (Ruth Cooper) Lutheran Services Florida, Inc. Man Tech Telecommunications & Info. Manatee Glens Corporation Mental Health Care, Inc. Mental Health Resource Center (MHRC) NAMI of Collier County Northside Mental Health Center, Inc. Operation Par, Inc. Peace River Ctr. for Personal Develop. Personal Enrichment Through MH Svcs. Phoenix Houses of Florida Polk County Drug Court Premier Behavioral Solutions of FL. Project Return Florida, Inc. Psychological & Neurobehavioral Svcs Southwest Florida Addiction Services Success 4 Kids & Families, Inc. Suncoast Ctr Community Mental Health Tampa Crossroads, Inc. Tenth Judicial Circuit of Florida The Harbor Behavioral Health Care Inst Tri-County Human Services, Inc. Volunteers of America of Florida Westcare Florida, Inc. Winter Haven Hospital, Inc. Youth & Family Alternatives, Inc. Youth and Family Center Services of FL
Program Name
Type of Service
Address Line 1
Address Line 2
City
State	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip
Facility Phone
Staff Involved

Complaint Details
Complainant Source	Agency Representative Consumer Current Staff Member Family Member Former Staff Member Friend Other Other Healthcare Provider
Type of Complaint	Administrative Clinical Other
Complaint Description	Describe what happened, including when and how; who was involved; date and time of event; staff member(s) involved; location of event; have any other agencies (ombudsman, police, etc) been contacted regarding this issue
Options for Resolution	No action required, just wanted to inform CFBN of event Would like CFBHN to explore the complaint/grievance