Contact Information
Optional Contact Information If you want DMHA to discuss the concern/complaint with you, please provide contact information and preferred method of contact:
Name of Person Completing Form
Phone	Preferred Method of Contact
Email	Preferred Method of Contact
Program, Participant, and Provider
Service Program In which program is the Participant enrolled?*	-- Select A Program -- 1915(i) CMHW Services PRTF Transition Waiver MFP PRTF Demonstration Grant Unknown
Name of Participant (Optional)
Name of Provider
Description of Grievance or Complaint
Grievance or Complaint Please describe the complaint or issue. Include details such as persons, services and dates involved, as applicable.*
Date Complaint Occurred*
Additional Information
You can also submit a Complaint Report to the Indiana Division of Mental Health and Addiction (DMHA) via postal mail or secure fax.
Mail: Indiana Division of Mental Health and Addiction          Attn: DMHA Youth Services          402 W. Washington St, W353          Indianapolis, IN 46204	Fax: (317) 233-1986