Human Services Agency

Consumer Complaint

Name of Client

Contact Number

Date of Birth

Name of Complainant

Contact Number

Relationship to Client

Date

Program

Please select one Child Protective Services Foster Care Services Adoption Services Child Care and Early Childhood Services Clinical Services Administration Other Adult Group Care Nursing Home Community Assistance Center Crossroads Sober 24 Homeless Support Washoe County Housing Burial and Cremation Services Administration Other Nutrition Adult Day Health Senior Centers Mental Health Support Representative Payee & Homemaker Services Case Management Volunteer Services Administration Other

Please describe your complaint