I, __________________________________, am filing this grievance with the Disability Law Center for the following reasons.  (Please complete sentences 1, 2, or 4, whichever applies to your grievance.)


  1.  I was denied services by DLC.  Explain:



  1. I am dissatisfied with the services that I am receiving.  Explain:



  1.  I am dissatisfied that my case was closed and that I have been denied further services.  Explain:



  1. I receive mental health services, or I am writing on behalf of one or more such individuals, and I have concerns about whether DLC is complying with legal requirements.  Explain. 





Signature: ____________________________________


Address: _____________________________________




Phone #: __(_______)___________________________


Mail Completed form to:


Disability Law Center

11 Beacon Street, Suite 925

Boston, MA 02108