PSYCHIATRIC PATIENT RIGHTS COMPLAINT

COMPLAINT INFORMATION

Date of Complaint: ________________________________________

Complaint Number (for office use): _________________________

Priority Level:
☐ Emergency (immediate danger/ongoing abuse or neglect)
☐ Urgent (serious rights violation requiring prompt action)
☐ Standard (rights violation - non-emergency)

PART I: COMPLAINANT INFORMATION

Section A: Person Filing Complaint

☐ I am the patient/individual whose rights were violated

☐ I am filing on behalf of another person (complete Section B)

Full Legal Name: __________________________________________

Date of Birth: ____________________________________________

Address: __________________________________________________

_______________________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Best Time to Contact: _____________________________________

Section B: Patient Information (if different from complainant)

Patient's Full Legal Name: _________________________________

Date of Birth: ____________________________________________

Patient ID Number (if known): _____________________________

Relationship to Patient: ___________________________________

Do you have legal authority to file on patient's behalf?
☐ Yes - Type: ________________________________________________
☐ No - Explain basis for filing: _______________________________

Patient's Current Location:
☐ Psychiatric hospital: _______________________________________
☐ General hospital psychiatric unit: ___________________________
☐ Community mental health facility: ____________________________
☐ Residential treatment facility: ______________________________
☐ Discharged - Current address: _______________________________
☐ Unknown

PART II: FACILITY/PROVIDER INFORMATION

Section A: Facility Where Incident(s) Occurred

Facility Name: ____________________________________________

Facility Type:
☐ State psychiatric hospital
☐ Private psychiatric hospital
☐ General hospital psychiatric unit
☐ Community mental health center
☐ Residential treatment facility
☐ Crisis stabilization unit
☐ Outpatient mental health clinic
☐ Other: _____________________________________________________

Facility Address:
_______________________________________________________________
_______________________________________________________________

Facility Phone: ___________________________________________

Unit/Ward Name (if applicable): ____________________________

Section B: Individual(s) Involved in Violation

PART III: NATURE OF COMPLAINT

Section A: Type of Rights Violation

Check all that apply:

ABUSE
☐ Physical abuse (hitting, slapping, pushing, rough handling)
☐ Sexual abuse or sexual harassment
☐ Verbal/emotional abuse (threats, humiliation, intimidation)
☐ Financial exploitation
☐ Other abuse: _______________________________________________

NEGLECT
☐ Failure to provide adequate food/water
☐ Failure to provide adequate clothing
☐ Failure to provide adequate hygiene/bathing
☐ Failure to provide necessary medical care
☐ Failure to provide necessary psychiatric care
☐ Failure to protect from harm
☐ Failure to supervise adequately
☐ Other neglect: _____________________________________________

TREATMENT RIGHTS
☐ Forced medication without proper authorization
☐ Medication errors or inappropriate medication
☐ Failure to obtain informed consent
☐ Denial of right to refuse treatment
☐ Inappropriate use of seclusion
☐ Inappropriate use of restraints
☐ Denial of access to treatment records
☐ Inadequate treatment planning
☐ Failure to provide treatment in least restrictive setting
☐ Experimental treatment without consent
☐ Other treatment violation: __________________________________

COMMUNICATION RIGHTS
☐ Denial of access to telephone
☐ Denial of mail privileges
☐ Denial of visitor access
☐ Denial of access to attorney
☐ Denial of access to patients' rights advocate
☐ Denial of access to clergy/spiritual advisor
☐ Censorship of communications
☐ Other communication violation: _____________________________

PERSONAL RIGHTS
☐ Denial of personal property
☐ Violation of privacy
☐ Denial of religious practices
☐ Discrimination based on disability
☐ Discrimination based on race/ethnicity
☐ Discrimination based on gender/sexual orientation
☐ Denial of adequate living conditions
☐ Restriction of movement without justification
☐ Other personal rights violation: ____________________________

PROCEDURAL RIGHTS
☐ Failure to provide rights notice
☐ Illegal detention/commitment
☐ Denial of hearing rights
☐ Denial of right to counsel
☐ Failure to conduct timely review
☐ Improper discharge
☐ Retaliation for exercising rights
☐ Other procedural violation: _________________________________

CONFIDENTIALITY VIOLATIONS
☐ Unauthorized disclosure of medical information
☐ Unauthorized disclosure of mental health records
☐ Breach of HIPAA
☐ Breach of state confidentiality laws
☐ Breach of 42 CFR Part 2 (SUD records)
☐ Other confidentiality violation: ____________________________

Section B: Specific Rights Violated

List specific patient rights that were violated (reference state law or facility policy if known):

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

4. ____________________________________________________________

PART IV: INCIDENT DETAILS

Section A: Date(s) and Time(s)

Date(s) of Incident(s): ____________________________________

Time(s) of Incident(s): ____________________________________

Is the violation ongoing? ☐ Yes ☐ No

If ongoing, when did it begin? ________________________________

Section B: Location of Incident

Specific location within facility:
_______________________________________________________________

Section C: Detailed Description of Incident(s)

Please provide a detailed, chronological description of what happened. Include:
- What occurred before, during, and after the incident
- Who was involved (staff, other patients, visitors)
- What was said or done
- How you or the patient were affected
- Any injuries sustained

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

(Attach additional pages if needed)

Section D: Witnesses

Were there witnesses to the incident? ☐ Yes ☐ No

Section E: Evidence

What evidence exists to support this complaint?

☐ Medical/treatment records
☐ Photographs of injuries
☐ Video/audio recordings
☐ Written statements from witnesses
☐ Incident reports
☐ Medication administration records
☐ Seclusion/restraint documentation
☐ Emails or written communications
☐ Other: _____________________________________________________

Location of evidence: ______________________________________

PART V: HARM AND IMPACT

Section A: Physical Harm

☐ No physical harm occurred

☐ Physical harm occurred:

Description of injuries:
_______________________________________________________________
_______________________________________________________________

Medical treatment received:
☐ No treatment needed
☐ First aid at facility
☐ Emergency room visit
☐ Hospitalization
☐ Ongoing medical care

Healthcare provider(s) who treated injuries:
_______________________________________________________________

Section B: Psychological/Emotional Harm

☐ No psychological harm occurred

☐ Psychological harm occurred:

Description of psychological impact:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Section C: Other Impacts

Describe any other impacts (financial, social, legal, etc.):
_______________________________________________________________
_______________________________________________________________

PART VI: PRIOR COMPLAINTS AND ACTIONS

Section A: Prior Complaints to Facility

Have you complained to the facility about this issue?
☐ Yes ☐ No

If yes:

Date(s) of complaint(s): ___________________________________

Who did you complain to? ___________________________________

How was the complaint made? ☐ Verbal ☐ Written ☐ Both

What was the response?
_______________________________________________________________
_______________________________________________________________

Section B: Complaints to Other Agencies

Have you filed complaints with any other agencies?

☐ State licensing board
Agency: ____________________________________________________
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ State mental health authority
Agency: ____________________________________________________
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ Protection and Advocacy organization
Agency: ____________________________________________________
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ Office for Civil Rights (OCR)
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ The Joint Commission
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ State Attorney General
Date filed: ________________________________________________
Complaint number: __________________________________________

☐ Law enforcement (if criminal conduct)
Agency: ____________________________________________________
Date filed: ________________________________________________
Report number: _____________________________________________

☐ Other: _____________________________________________________
Date filed: ________________________________________________
Reference number: __________________________________________

Section C: Legal Action

Have you filed a lawsuit or retained an attorney?
☐ Yes ☐ No

If yes:

Attorney name: ____________________________________________

Contact information: ______________________________________

Court case number (if filed): ______________________________

PART VII: RESOLUTION SOUGHT

Section A: Desired Outcome

What resolution are you seeking? (check all that apply)

☐ Investigation of the incident(s)

☐ Disciplinary action against staff member(s)

☐ Change in facility policies/procedures

☐ Training for staff

☐ Apology from facility/staff

☐ Compensation for damages/injuries

☐ Correction of medical/treatment records

☐ Transfer to different facility/unit

☐ Release from facility

☐ Restoration of privileges/rights

☐ Criminal prosecution referral

☐ Other: _____________________________________________________

Section B: Specific Requests

Please describe specifically what you want to happen as a result of this complaint:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

PART VIII: AUTHORIZATION AND CONSENT

Section A: Release of Information

To investigate this complaint, we may need to access medical records and communicate with facility staff and other agencies.

☐ I authorize the release of relevant medical and treatment records for purposes of investigating this complaint

☐ I authorize communication with the facility regarding this complaint

☐ I authorize communication with other agencies as necessary

☐ I do NOT authorize record release - Please contact me to discuss

Signature: ________________________________________________

Date: _____________________________________________________

Section B: Consent for Representation (if applicable)

☐ I request that a patients' rights advocate contact me

☐ I request legal representation (if available)

☐ I authorize [ORGANIZATION NAME] to act on my/the patient's behalf

PART IX: STATE-SPECIFIC FILING INFORMATION

California

Primary Filing Agencies:

1. County Patients' Rights Advocate
   - Contact through county mental health department
   - Mandatory investigation of rights violations in facilities

2. Disability Rights California
   - Phone: 1-800-776-5746
   - Website: www.disabilityrightsca.org
   - Protection & Advocacy organization for California

3. California Department of State Hospitals (for state hospital complaints)
   - Website: www.dsh.ca.gov

4. California Department of Public Health (licensing complaints)
   - Website: www.cdph.ca.gov

Time Limits: File as soon as possible; some complaints have 180-day limits

Texas

Primary Filing Agencies:

1. Disability Rights Texas
   - Phone: 1-800-252-9108
   - Website: www.disabilityrightstx.org
   - Protection & Advocacy organization for Texas

2. Texas Health and Human Services Commission - Office of Consumer Services and Rights Protection
   - Investigates complaints within 24 hours of receipt
   - Aims to resolve within 7 working days

3. Texas Department of State Health Services
   - Licensing and regulatory complaints

Time Limits: File within 180 days for civil rights complaints

Florida

Primary Filing Agencies:

1. Disability Rights Florida
   - Phone: 1-800-342-0823
   - Website: www.disabilityrightsflorida.org
   - Protection & Advocacy organization for Florida

2. Florida Agency for Health Care Administration
   - Hospital licensing complaints
   - Website: www.ahca.myflorida.com

3. Florida Statewide Advocacy Council
   - Advocacy for mental health facility residents

Time Limits: File as soon as possible; statutory limits vary by claim type

New York

Primary Filing Agencies:

1. Disability Rights New York
   - Phone: 1-800-993-8982
   - Website: www.drny.org
   - Protection & Advocacy organization for New York

2. New York State Office of Mental Health
   - Bureau of Inspection and Certification
   - Website: www.omh.ny.gov

3. Mental Hygiene Legal Service
   - Court-appointed service for involuntary patients

4. Commission on Quality of Care and Advocacy for Persons with Disabilities

Time Limits: File within 180 days for civil rights complaints

PART X: CERTIFICATION

I certify that the information provided in this complaint is true and accurate to the best of my knowledge. I understand that providing false information may result in denial of this complaint and potential legal consequences.

Complainant Signature: _____________________________________

Date: _____________________________________________________

Print Name: _______________________________________________

PART XI: SUBMISSION CHECKLIST

Before submitting this complaint, ensure you have:

☐ Completed all relevant sections of this form

☐ Attached copies (not originals) of supporting documentation

☐ Signed and dated the complaint

☐ Signed authorization for release of records (if applicable)

☐ Made a copy of the completed complaint for your records

☐ Identified the correct agency to receive the complaint

FOR OFFICE USE ONLY

Date Received: ____________________________________________

Received By: ______________________________________________

Complaint Number Assigned: _________________________________

Priority Classification: ___________________________________

Investigator Assigned: _____________________________________

Date Assigned: ____________________________________________

Investigation Deadline: ____________________________________

Status:
☐ Under Investigation
☐ Pending Additional Information
☐ Substantiated
☐ Unsubstantiated
☐ Resolved
☐ Referred to Other Agency
☐ Closed

RESOURCES

National Disability Rights Network: https://www.ndrn.org/
(Find your state's Protection & Advocacy organization)

SAMHSA National Helpline: 1-800-662-4357

NAMI Helpline: 1-800-950-NAMI (6264)

HHS Office for Civil Rights (HIPAA complaints): https://www.hhs.gov/ocr/

The Joint Commission (hospital accreditation complaints): https://www.jointcommission.org/

This complaint form should be submitted to the appropriate state agency, Protection and Advocacy organization, or facility grievance office. Keep copies of all documents submitted. If you believe you are in immediate danger, contact local law enforcement (911) or a crisis hotline immediately.