ADAP Grievance Form

Use this form to file a grievance with ADAP.

You may also file your grievance by providing us a recording that answers the questions on this form.

We will be glad to provide any help you need in making your grievance.

You must send us your grievance within 30 days following the decision of this agency with which you disagree.

Please complete all sections that apply to your concerns.  Enter your name and the address you would like your response mailed to.

 

Name:        

Address:    

City:            State: Zip:
 

Phone:       

Date of Request:

Signature:    

Please describe the type of help that you requested from ADAP:


ADAP told me it would not provide me services. (Please indicate the
date on which you were informed of this decision.) I disagree with
this decision because:

I am unhappy with the services that I am receiving because:


I disagree with ADAP's decision to limit services to me or to close my
case.  (Please indicate the date on which you were informed of this
decision.) I disagree with this decision because:


I believe that ADAP has treated me unfairly or has not carried out its
legal obligations, because:


Please add any additional explanation if necessary: