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
Complaint Category (choose all that apply)*
Name of Participant
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