Confidential Form

This form may be used to make a request for services with the Mental Health Association of Portland. Please complete the following information. Please attach any photocopies of documents, including jail records, psychological records, counseling records and medical records if available, that are pertinent to your complaint. State in detail all the facts which you believe justify your complaint.

The organization is now reviewing requests for services in relation to: county jails in Oregon, hospital emergency rooms in Oregon.

Note - the organization can only review requests for services for incidents which occurred in Oregon, and in the last twelve months.

Your first name

Your middle name

Your last name

Your city

Your phone number

Your email

Is the complainant the client?Yes - I am the clientNo - I am a friend or family member of the clientNo - I am the legal representative of the client

Specific Information

County jail name

What are the dates that you/client were in jail

Have you contacted the jail directly about the alleged incident(s)?YesNo

Do any clinical providers have knowledge of the alleged incident(s)?YesNo

Is law enforcement involved or are there any pending or ongoing court matters? YesNo

Have you filed a complaint elsewhere? YesNo

Your complaint details (optional)

Additional Documentation

Please attach any documents, including jail records, psychological records, counseling records and medical records if available that are pertinent to your complaint.

Please print sign and attach this document to the complaint form.

LINK TO PDF - TO BE CREATED

I hereby certify that the above information is true to the best of my knowledge.

You will receive an email message acknowledging receipt of this form within three business days.

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