Kerry's Place Complaint/Feedback Form

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Pursuant to SS 511 Policy on Complaints/Feedback Process, Kerry’s Place recognizes the right of each individual/family to provide their feedback in regards to decisions and actions carried out by our organization. Kerry’s Place encourages individuals/families to bring their questions and concerns forward so that they may be dealt with positively and appropriately.

"Complaint" is an expression of dissatisfaction related to the services and/or supports that are provided by a service agency. A complaint may be expressed by a person receiving services and supports from the service agency, or a person acting on their behalf, or by the general public, regarding the services and supports that are provided by the service agency.

"Feedback" may be positive or negative (including complaints) and is related to the services and/or supports that are provided by a service agency.

What is your reason for contacting Kerry's Place? *

I have a complaint

I would like to provide feedback

First name *

Last name *

Mailing address *

Telephone number *

Email address *

What is your association to Kerry's Place *

Parent/legal guardian to a person supported by Kerry's Place

Supported person receiving support and services by Kerry's Place

Substitute Decision Maker (if other than a family member)

Advocate for the supported person (other than a family member)

Partner agency

Ministry

Kerry's Place employee

Volunteer

Member of the general public (no association)

Preferred method of contact *

Please select the type of complaint/feedback to be addressed by Kerry’s Place *

Complaint/feedback about policy or practice at Kerry's Place

Complaint/feedback about quality of service provided to person(s) supported by Kerry's Place

Complaint/feedback about due process on behalf of person(s) supported by Kerry's Place

Complaint/feedback about conduct of Kerry's Place employee(s)

Complaint/feedback about refusal of service/level of service

Other:

Please describe the nature of the complaint/feedback. *

When did this take place? *

Have you contacted a Kerry's Place representative to respond to your complaint/feedback? *

Yes

If yes, who did you contact and when?

Has there been an attempt to address your complaint/feedback?

Submit

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