State of Indiana
DMHA - COMPLAINT REPORT
User Guide
Provider Summary Report
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
Complaint Category (choose all that apply)
*
Access Site
CMHW
Other
Name of Participant
(Optional)
County
*
-- Select A County --
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
DeKalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
St. Joseph
Scott
Shelby
Spencer
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Name of Provider #1
Name of Provider #2
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
Youth and family members may also submit a complaint report to the Indiana Division of Mental health and Addiction (DMHA) via postal mail.
Mail:
Indiana Division of Mental Health and Addiction
Attn: DMHA Youth Services
402 W. Washington St, W353
Indianapolis, IN 46204