First Name (required) Last Name (required) Phone Number (required) Your Email (required) Relationship to Provider (required) Other I claim direct, first-person knowledge related to this grievance (required) Provider Name (Facility against whom Grievance is being filed) (required) Provider Street Address Provider State Provider Zip Code Provider Primary Contact Provider Phone Grievant alleges Provider non-compliance with NARR Core Principles listed below. (Please select all that apply) Residence Operates with Integrity Residence Upholds Residence Rights Residence is Recovery-Oriented Residence is Peer Staffed and Governed Residence Promotes Health Residence Provides a Home Residence Inspires Purpose Residence Cultivates Community Residence Promotes Recovery Promotes Health and Safety Residence is a Good Neighbor Your Message Other Nature of Grievance (Please provide a detailed narrative explaining the nature of the grievance below) Supporting Documentation In filing this grievance, I understand that it may be necessary for INARR to disclose information pursuant to this grievance to the subject Provider as well as to external agencies including, but not limited to the Department of Children & Families - Substance Abuse Licensure Division, Idinana Attorney General’s Office of Consumer Protection, Indiana Department of Law Enforcement, Local Law Enforcement Agencies and Local Code Enforcement Agencies. For this reason, INARR can make no warranty that it will protect the source of this information. However, an attempt is made to withhold disclosure of the source to the extent that is reasonably possible. I authorize unrestricted use of the information filed in this grievance by the Indiana Affiliation of Recovery Residences (INARR) to act as it deems prudent and necessary in accordance with the published INARR Compliance Audit Protocol. Please do not include any personal identifying information or protected health information about any individual. I certify that the above information is entirely accurate to the best of my knowledge.