Complaint form

PART I – IDENTIFICATION OF THE COMPLAINANT

First name *

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Name *

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Address *

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City *

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Province *

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Zip *

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Telephone to reach you *

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E-mail *

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If the user is a minor or incapacitated, the representative of the user concerned by the complaint

Status of the user representative

Name

First name

Address

City

Province

Zip

Telephone to reach you

E-mail

PART II – THERAPIST IDENTIFICATION

Name *

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First name *

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Address

City

Province

Zip

Telephone to reach you

E-mail

RITMA membership number assigned to the therapist *

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PART III – QUESTIONS AND DESCRIPTION OF YOUR COMPLAINT

Has the care received harmed your health? *

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What were the reasons for your consultations? *

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Did the results obtained following the services rendered by the therapist meet your expectations? *

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Did the therapist give you receipts during your visits, if so attach the copy(ies)? *

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If not, could you list us the dates of consultations? *

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How many care visits do you expect with this therapist? *

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How much money do you think you paid to your therapist and how did you pay for the consultations? *

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In your complaint process, did you first try to discuss your dispute with the therapist? *

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If so, what is the result of your exchange? *

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Have you contacted a lawyer or another organization in order to proceed with a lawsuit in connection with your complaint and if so, specify? *

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Yes

If yes, please provide details

If so, do you have a file number? *

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Do you have a relationship other than professional with the therapist and if so, specify? *

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Yes

If yes, please provide details

What do you think would be the best solution to resolve this complaint? *

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In addition to the questionnaire above, please send us your detailed version of the facts that led you to file your complaint today.

We invite you to consult the RITMA code of ethics, available at all times on our website at RITMA.CA, which will inform you about the commitments and responsibilities of the therapist or the intervener targeted by your complaint.

PART IV – RELEVANT DOCUMENTS SUPPORTING THE DESCRIPTION OF YOUR COMPLAINT

Please attach to this form all copies of documents that you consider important and that can help us in the analysis of your complaint, in particular a copy of a contract, invoice, statement, receipt, proposal, document needs analysis or other that would have been given to you by your therapist. Please list the numbered documents you intend to attach to your complaint.

File 1

Choose file

File 2

Choose file

File 3

Choose file

File 4

Choose file

File 5

Choose file

File 6

Choose file

I, the undersigned, hereby *

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confirm that the above information and statements are true and undertake to collaborate to the best of my knowledge in the investigation process that will be initiated by my complaint. I also hereby authorize the members of the ethics committee as well as the members of the RITMA board of directors to have access to the personal information and the complete content of this complaint necessary for the investigation process.

Signature of complainant

Enter your signature *

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Date of signing *

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