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Compliment / Complaint Form

2. This form is for the Chesapeake Integrated Behavioral Healthcare (CIBH) only. To share a compliment/complaint about another City of Chesapeake Department, please call 757-382-2489.

   The City of Chesapeake is committed to providing the best possible service to our customers. In the event you feel that Chesapeake Integrated Behavioral Healthcare (CIBH) may have exceeded your expectations or that we may have failed to meet our professional standard, please file a customer compliment/complaint using this form or by calling the Client Rights Advocate at 757-547-9334. CIBH will not use email to respond to questions that involve personally identifiable health information, so please include a phone number where we can reach you to discuss your specific situation. We will use email to answer general questions and to provide links to more information.

4. I understand this Compliment/Complaint Form is for Chesapeake Integrated Behavioral Healthcare (CIBH) only. For other departments, please call 757-382-2489.*

   1. I understand
6. CIBH service received / requested*
8. Your Contact Information
10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip Code
19. Phone Number*
20. Email Address
22. Type:

    1. Compliment
    2. Complaint
24. Please describe your interaction with the CIBH:
26. CIBH Employee Name
27. Would you like a follow-up call regarding this comment?

    1. Yes
    2. No
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field