Confidential Privacy Violation Form

Name (Optional)

First Name

Last Name

Choices in Community Living, Inc. is committed to protecting the privacy of our clients to the greatest extent possible. All information about those we serve, including their names, images and health information, may be shared only with those who need to know in order to do their jobs.

If you have information relating to a possible violation of privacy, please let us know as many details as possible. Our promise to you is that we will never reveal your name, or if you are reporting anonymously, we will respect your privacy and will make no attempts to try to identify you.

Please tell us as much information as possible about any potential privacy violation that may involve someone we serve at Choices in Community Living. Please include the names of clients involved if you can. Please be clear in letting us know what happened and how you think a violation may have occurred.*