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If you wish to report another type of discrimination, please specify below.

By signing this form, I authorize Orange Grove Center to discuss/disclose my personal and protected health information (via email, telephone, etc.) for the purposes of addressing and resolving this inquiry. I authorize Orange Grove Center to share information contained within this form with federal, state, and/or local agencies for law enforcement purposes concerning violations of the law.

All inquiries and complaints will receive a response within seven (7) business days. Depending on the nature and complexity of the inquiry, additional time may be necessary to resolve your issue. If you have any questions regarding this form, please call our phone number listed above and below this form.