Dissatisfaction report

This document is not an official complaint, it is part of the process that may lead to a complaint, and does not require you to make a formal one, however it shares with us your remarks on therapists or schools:

PART 1 – IDENTIFICATION

YOUR CONTACT INFORMATION

Name *

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First name *

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Date of birth

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Residential address

No.

Street

App.

City

Province

Zip

Telephone to reach you *

This field is required

E-mail *

This field is required

CONTACT INFORMATION OF THE CONCERNED

Name

First name

Member Number

Residential address

No.

Street

App.

City

Province

Zip

Telephone to reach you

E-mail

PART 2 – DESCRIPTION OF YOUR DISSATISFACTION

Please describe chronologically the events that led you to start this procedure (use another sheet if needed) *

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In your procedure, have you already contacted, in writing or by phone: *

The association

The concerned therapist

A lawyer

Another organisation

No other procedure have been initiated

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What would be, for you, the best way to solve the situation? *

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In your opinion, what can we concretely do to help you? *

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Signature *

Enter your signature

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Date *

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Dissatisfaction report

Dissatisfaction report

PART 1 – IDENTIFICATION

YOUR CONTACT INFORMATION

Residential address

CONTACT INFORMATION OF THE CONCERNED

Residential address

PART 2 – DESCRIPTION OF YOUR DISSATISFACTION

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