MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION COMPLAINANT FORM REGARDING RESIDENTIAL TREATMENT AGENCIES FOR CHILDREN AND YOUTH/CHILD PLACING AGENCY LICENSURE
IDENTIFYING INFORMATION (COMPLETED BY COMPLAINANT)
NAME	HOME TELPHONE NUMBER	WORK TELEPHONE NUMBER
HOME ADDRESS
NAME OF LICENSED RESIDENTIAL TREATMENT AGENCY/CHILD PLACING AGENCY
COUNTY
SECTION A. (TO BE COMPLETED BY COMPLAINANT)
COMPLAINT ISSUE
BRIEFLY DESCRIBE THE SITUATION WHICH CAUSED YOU TO FILE THIS COMPLAINT. INCLUDE THE DATE IT OCCURRED, WHERE IT OCCURRED, AND NAMES AND OTHER IDENTIFYING INFORMATION OF THOSE INVOLVED. PLEASE USE ADDITIONAL SHEETS IF NECESSARY.
DESIRED OUTCOME
STATE WHAT YOU WOULD LIKE TO HAVE HAPPEN WITH REGARD TO THE ABOVE COMPLAINT. PLEASE USE ADDITIONAL SHEETS IF NECESSARY.
ATTEMPTS TO RESOLVE THE COMPLAINT
PLEASE DESCRIBE ALL ACTIONS THAT HAVE BEEN TAKEN TO RESOLVE THE ISSUE. PLEASE INCLUDE DISCUSSIONS WITH ADMINISTRATIVE AND, IF PERTINENT, OTHER STAFF OF THE LICENSED RESIDENTIAL TREATMENT AGENCY/CHILD PLACING AGENCY. PLEASE USE ADDITIONAL SHEETS IF NECESSARY.
COMPLAINANT’S SIGNATURE	DATE
SECTION B (TO BE COMPLETED BY THE REGIONAL LICENSING CONSULTANT, RESIDENTIAL PROGRAM UNIT)
DESCRIBE ACTIONS TAKEN TO RESOLVE THE COMPLAINT AT LEVEL ONE. USE ADDITIONAL SHEETS IF NECESSARY.
REGIONAL LICENSING CONSULTANT SIGNATURE	DATE
SECTION C (TO BE COMPLETED BY THE STATE SUPERVISOR, RESIDENTIAL PROGRAM UNIT)
DESCRIBE ACTIONS TAKEN TO RESOLVE THE COMPLAINT AT LEVEL TWO. USE ADDITIONAL SHEETS IF NECESSARY.
STATE SUPERVISOR SIGNATURE	DATE
SECTION D (TO BE COMPLETED BY DIVISION DIRECTOR/DESIGNEE)
DESCRIBE ACTIONS TAKEN TO RESOLVE THE COMPLAINT AT LEVEL THREE. USE ADDITIONAL SHEETS IF NECESSARY.
DIVISION DIRECTOR’S/DESIGNEE’S SIGNATURE	DATE

DESCRIPTION OF COMPLAINT PROCESS
The Children’s Division (CD) Residential Program Unit (RPU) is committed to providing the best possible regulatory services for licensed residential child care/child placing agencies in the most professional manner. What is a complaint? For the purposes of the complaint process utilizing this form, a complaint is an issue that relates to a potential violation of Chapter 50, Chapter 71, and/or Chapter 73 of the CD Residential Treatment Agency and/or Child Placing Agencies rules. Who may complain? Anyone who has reasonable cause to think that there has been a violation of Chapter 50, Chapter 71, and/or Chapter 73 of the CD Residential Treatment Agency or Child Placing Agencies rules with regard to a licensed residential treatment agency/child placing agency. Children under the age of twelve (12) years will need the assistance of a parent, guardian, out-of-home care provider, or Guardian ad Litem (GAL). What is not a complaint pursuant to this form? Child abuse/neglect that requires calling the Missouri Statewide Child Abuse/Neglect Hotline at 1-800-392-3738 (or out-of-state callers, 1-573-751-3448) pursuant to Chapter 210 RSMo; Specific case management or other grievances related issues that do or do not pertain to the grievance process pursuant to Form CS-131, Service Delivery Grievance; Media inquiries subject to Department of Social Services and Children’s Division communications policies and procedures; and Complaints received by the Residential Program Unit from Department of Social Services staff, Children’s Division staff, or other governmental entities’ staff, including, but not limited to, elected officials, administrative, professional, and/or support staff within the regular course of state business. The complaint process pertaining to this form is designed to resolve complaints at the lowest level possible. Before filing this complaint form, please be sure that you have attempted to resolve the complaint through discussions with the respective administration of the licensed residential treatment agency/child placing agency. If you are still not satisfied, then you may file a formal complaint by filling out section A of this form and sending it to: Residential Program Unit, PO Box 88, Jefferson City, MO 65103.
STEPS IN THE COMPLAINT PROCESS
Level 1: Fill out Section A of this form; Send the completed form to: Residential Program Unit, PO Box 88, Jefferson City, MO 65103; Work with the Regional Licensing Consultant, Residential Program Unit, to resolve the problem; and Within fifteen (15) working days of your discussion with the Regional Licensing Consultant and other pertinent participants (if necessary), you should receive a written response to your complaint including the form you completed.	If resolved
IF NOT RESOLVED
Level 2: Within fifteen (15) calendar days of receiving the Level 1 response, send a copy of the form you received in Level 1 to: Residential Program Unit, PO Box 88, Jefferson City, MO 65103 along with a letter briefly explaining the reason you do not agree with the Level 1 response; Work with the State Supervisor, Residential Program Unit to resolve the complaint; and Within fifteen (15) working days from your conversation with the State Supervisor, you should receive a written response to your complaint including the form you completed.	If resolved
IF NOT RESOLVED
Level 3: (THIS IS THE FINAL LEVEL) Within fifteen (15) calendar days of receiving the Level 2 response, send a copy of the form you received in Level 2 to: Children’s Division Director, PO Box 88, Jefferson City, MO 65103 along with a letter briefly explaining the reason you do not agree with the Level 2 response; Work with the Division Director/Designee to resolve the complaint; and Within fifteen (15) working days from your conversation with the Division Director/Designee, you should receive a written response to your complaint including the form you completed. If not resolved, you may seek judicial review pursuant to 210.526 RSMo.
You may ask a friend, family member, or other supportive person to help you fill out this form. During the process, you may be talking to Children’s Division staff in person or by telephone. It is not required that you come into a Children’s Division office in person.