If you live in Michigan, and believe that one of your rights has been violated, you may use this form to file a formal grievance. Our office will review all submitted grievances and may conduct an investigation. If an investigation is conducted, the results of the investigation will be shared with you in writing.  Please contact Heather Kapustka at kapustkh@stvcc.org if you have any further questions.

    I. To be completed by the STVCC client filing the Complaint/Grievance

    Client's First Name (required)

    Client's Last Name (required)

    Client's Address

    Street

    City

    State

    Postal Code

    Children's Home Unit Name

    Client's Phone Number (required) (Ex: XXX-XXX-XXXX)

    Client's Email Address (required)

    II. To be completed by the person filing the complaint/grievance on behalf of the client (if applicable)

    First Name

    Last Name

    Relationship to Client

    Address

    Street

    City

    State

    Postal Code

    Children's Home Unit Name

    Phone Number

    Email Address

    III. Complaint/Grievance Information

    Date of the Alleged Violation (required)

    Location of the Alleged Violation (required)

    What right was violated? (required)

    IV. Complaint/Grievance Description

    Is this complaint/grievance about a STVCC staff member? (required)

    YesNo

    If YES, name of STVCC staff member:

    Please Describe What Happened (required)

    What would you like to see happen in order to correct the problem? (required)

    V. Acknowledgement

    I declare that all statements contained in this submission are true and that any misrepresentation or omission may result in rejection of my grievance

    YesNo

    Typing my name in the box below certifies my signature and submission of my grievance.

    Client Signature (required)

    Date (required)

    Name of person assisting client (if applicable)