Health & Mental Health Services

Jeffrey Goodman Special Care Clinic

Mental Health Services
Sexual Health Program
Womens Health Program
CLIENT RELATIONS FORM
Los Angeles LGBT Center

Please fill out this form as completely as possible. Your concern will be documented and reported, and then it will be
forwarded to the Quality Coordinator and to the appropriate Program Manager for review. Someone will contact you, if
indicated.
Client Name _____________________________________________ Date of Incident ___________________
Phone Number ___________________________________________
Nature of Concern/Problem

Appointment Access Rules or Regulations Problem With Staff

Telephone Callback Referral Billing
Quality of Care Wait Time Other

Describe your concern ________________________________________________________________________

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Client Signature ______________________________________ Todays Date ____________________________

To Be Completed By Staff Only

Action Taken To Resolve Concern or Problem _____________________________________________________
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Outcome ___________________________________________________________________________________
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Staff Signature __________________________________________Date ________________________________

Form HS1190 (Rev. 6/14)