SAMH Licensing

Complete this form to submit a formal complaint against the facility. Should you wish to consult with the Department prior to submitting a formal complaint, please reach out to The Department. A list of Regional Contacts can be found on our website: https://www.myflfamilies.com/services/licensing/samh

PLEASE NOTE: Florida has a very broad public records law (Chapter 119, F.S.). All emails to and from the Department are kept as public record.

Your Information (Complainant)

Basic Information

First Name:

Last Name:

Email Address:

Telephone Number:

Note: If you wish for the Department to contact you about this complaint, please share your name and contact information such as Telephone Number or E-mail address.

Address Information

Address Line 1:

Address Line 2:

City:

State:

County:

Zip Code:

Respondent Information

* Required Fields

Note: If you do not find the right Provider or Site, please contact the regional office.

Provider:

Other:

Either select a Provider from the dropdown or enter a Provider name here

Provider License Number:

Please note that the license number is not the same as the site or provider number.

City:

County: *

Region:

State:

Zip Code:

Date Occurred:

Subject Matter:

Complaint Description: *

Describe your complaint in detail including the nature, frequency, duration, circumstances, and date(s) of the alleged violation.

Participants Involved:

Please list and describe any witnesses involved or any individuals that may have knowledge of the events.

Supporting Documents

Max 10 documents, 100MB each

Note: Do you have any files to submit as part of this complaint? If you are submitting the form online, you may upload up to 10 files. If you have printed this form, you can mail the additional documentation with your complaint form.

(Max 100MB per file)

File Name	Size	Actions
No documents uploaded

Acknowledgement