File a Complaint

Details: Created: 01 July 2022

First Call for Help of Itasca County

1007 NW 4th Street, Grand Rapids, MN 55744
Phone: (218) 326-8565 | Fax: (218) 4634
Consumer Complaint Form
Complaint Registered Against

Fill out the information of the person you want to file a complaint against.
Name *
Name of Division/Department: (If available)
Address of occurrence(If known)

Address

Street Address Line 2

City State

Zip Code
Office Phone Number(Of staff)(If known)
Person Registering Complaint

Please fill out your information
Mr. Mrs. Ms.
Name *

First Name Last Name Suffix
Relationship to client: *
If other please specify.
Address *

Address

Street Address Line 2

City State

Zip Code
Home Phone Number *
Work Phone Number
Client Information

Only if relationship is not self
Client Name *
Sex
Client Date of Birth *

Month Day Year
Date
Do you have Legal Authority to act on clients behalf? *
Details of Complain

Please fill out as accurately as possible.
DESIRED OUTCOME OF THIS COMPLAINT *
Date of Incident *

Month Day Year
Date
Date of Incident

Month Day Year
Date
Date of Incident

Month Day Year
Date
State your complaint in detail *
NOTICE: As much information as possible should be provided, in addition to any supporting documents pertaining to your specific complaint. Failure to provide sufficient information or documentation may prevent or delay the review of your complaint. The information will be used to determine whether a violation of the law or organization policy has occurred. If a violation is substantiated, the information may be transmitted to other agencies or government entities.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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Address: 1007 NW 4th Street, Grand Rapids MN 55744
Phone: (888) 812-4526
Fax: (218) 326-4634
Email: info@firstcall211.net

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