Complaint Submission Form
If you or someone you know are an individual receiving services with Envision Counseling and would like to report a complaint, please complete this form and we will work to resolve the issue as quickly as possible. If you provide us information to contact you, someone will be in touch with you soon.
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Concern reported by: *
Name of individual receiving services:
This question is optional. Even if you do tell us your name, we will do our best to protect your anonymity during our investigation and resolution process. However, if you would like to remain completely anonymous that is okay. We will still take all of the necessary steps to resolve the issue you report. We will not, however, be able to contact you for additional information or share with you what actions we took in response to your report.
Name of person submitting report (if different than above):
Please provide us with the best way for us to contact you (if applicable).
Example: Email Address and/or Phone Number
Description of concern. *
Please include details about the rights you feel were violated or concerns you have about the services you recieved.
Please tell us what you believe needs to happen to resolve your concern. *
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