Client Services Form

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We value your feedback and welcome any comments, suggestions and details of your satisfaction and/or dissatisfaction with the program or services. Please complete this form using as much detail as possible.

Full Name of Client:

Client Phone #:

Email:

Full Name of Person Providing Feedback:

Relationship to Client:

Phone #:

Email:

Resident House While in Treatment:

House Location:

Other Houses Client Resided and Approximate Dates:

Admission Date:

Discharge Date:

Inquiries:

Financial (Insurance, Reimbursement, Billing)

Medical (Medications)

Clinical (Program concerns)

Operational (Personal Property, Housing, Transportation)

Please provide as much detail as possible, including dates and names of Sovereign Health representatives whenever possible. If your feedback involves a phone conversation, include all phone numbers used to call Sovereign Health.

Requested Resolution:

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