form15 FR0176 Client Grievance Form SOUTHERN MINNESOTA BEHAVIORAL HEALTH CLIENT GRIEVANCE FORMName First Last PhoneDate MM slash DD slash YYYY Nature of Complaint:____________________________________________________ Please return form to: Southern Minnesota Behavioral Health 1407 S. State St. New Ulm, MN 56073Discussion / Resolution /Action Take:Clinical Director / Executive Director Signature First Last Date MM slash DD slash YYYY CAPTCHAF:\Common\Agency\Forms\FR0176 Client Grievance Form.doc 10/4/2021
