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ADP Home Licensing Home Complaint Report
State of California-Health and Human Services Agency

COMPLAINT REPORT
Department of Alcohol and Drug Programs
Quality Assurance Division
1700 K Street
Sacramento, CA 95814
Driving-Under-the-Influence
        Program
 		Narcotic Treatment
        Program
 Residential Recovery or
        Treatment Program
 Complainant Name:

  Program Name:
 Address:

  Program Address:
 City, State, Zip:

  City, CA, Zip:
 Phone:   DAY          EVE         PAGER

 County:
 Complainants Relationship to Provider:
Client/Patient
Staff
Executive Staff
Relative/Friend
Public/Govt Agcy 		Neighbor
Former Client
Former Staff
Other ___________
For Office Use Only
 Contact Name:
 Contact Phone:
 Provider License No.:
 Complaint No.:
Complainant waives confidentiality of his/her name and name of any person named in complaint, except provider clients/patients. (Not applicable to DUI program participants)   Yes   No
For Office Use Only   Reported:   By Letter    By FAX    In Person    By Telephone    By Email
Nature of Complaint
For Office Use Only
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Use additional pages as necessary to explain your complaint.

Complainant's Signature:________________________________________ Date: _____________________
(Continued on next page)

Nature of Complaint (cont.)
For Office Use Only
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Use additional pages as necessary to explain your complaint.

Complainant's Signature:_________________________________________ Date: ___________________