Creative Solutions

Is there a problem? 

If you are not satisfied with your experiences here we want to hear from you so that we can

provide our services to you in ways that we both find satisfactory. 

If you have a problem with anything about our practice, speak directly with Susan Griffith or Richard Cooper.

If the problem is with your therapy, talk to your therapist, Susan Griffith or Richard Cooper.

If you believe there has been some kind of violation of the confidentiality or the privacy of your records speak with, telephone, or email our Privacy Officer, Richard S.Cooper, Ph.D. and let us clarify and fix the situation.

If you are not satisfied or the problem still continues please fill out this simple form and we can assure you that it will be investigated and that we will try our best to fix it and to repair any damage that has been done. We will not in any way limit your care here or take any actions against you if you bring a problem to our attention.

Note: You do not have to sign this form if you do not want to. Thank you.

Client's name _______________________________                Date of birth _________

SS#  _________________  Telephone  _______________  Email ________________________

Client's address_________________________________________________________________

What is or was the problem? ______________________________________________________

______________________________________________________________________________

What would you like to see done about the problem?___________________________________

______________________________________________________________________________

________________________________________________            _____________

Signature of client or his or her personal representative.                Date

__________________________________________               ______________________

Printed name of client or personal representative (with relationship of representative to the client)                 

-----------------------------------------------------------------------------------------------------------------------------------------

Richard S. Cooper, Ph.D., Privacy Officer      (919) 942-3229     rcpianoman@yahoo.com

5102 Durham Chapel Hill Blvd., Ste. 207

Durham, NC  27707-3394