Complaint Form Who are you concerned about?*Senior's first and last nameWhere is the senior located?*Name of long term care facility or physical addressComplaint details*What action has anyone taken to resolve the complaint so far?Does the senior want ombudsman assistance?YesNoDon't know Senior's legal representative If senior has granted Power of Attorney or has a guardian, list name and number PoA holder or Guardian nameIf knownPoA holder or Guardian phoneIf known Care Coordinator If senior has Care Coordinator, list name and number:Coordinator nameIf knownCoordinator phoneIf known Complaintant Name*Name of person submitting this complaintKeep my information confidentialYesNoComplaintant Contact Information*PLEASE leave a phone number or email address. An ombudsman may need to contact you for more information.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.