State Seal of Indiana FSSA

State of Indiana


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    
Program, Participant, and Provider
Service Program
In which program is the Participant enrolled?*
Name of Participant
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