Partners BHM - Consumer Complaint Form

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Complaint/Concern Form

If you have a complaint or concern that you would like to make Partners BHM aware of or to investigate, use the form below to submit the information to the appropriate person(s) within the organization.

*denotes required fields

*Your Name:

*Phone (Contact) Number:

Format: 123-456-5555

Email Address:

*Complaint/ Concern:

*Some issues may require us to clarify the situation by contacting you for discussion. If necessary, may Partners Behavioral Health Management contact you to discuss your issue?

Yes, Partners BHM may contact me.
No, Partners BHM should NOT contact me

*There are times when we would need to share your personal information with the parties involved in order to rectify the issue. If your issue is deemed as such, may we share your information with the parties involved?

When necessary, Partners BHM may share my personal information with other parties involved
Partners BHM should keep my personal information confidential. I recognize that my issue may not be fully resolved without full disclorure of the situation

Partners Behavioral Health Management
Corporate Office | 901 S. New Hope Rd | Gastonia, NC | 28054 | Toll free: 877-864-1454