Professional Conduct Review Form

Please note, by completing and submitting this form, you are allowing the Aging Life Care Professional (Care Manager) in question to disclose information about the case in which you are filing a complaint.

The purpose of this process is to promote professional behavior by ALCA members. The ALCA Professional Review Process is not a dispute resolution mechanism, nor a means to pursue legal or financial remedies. Fee and similar contract disputes involving consumers are generally outside the scope of this process. We recommend that persons with such concerns discuss them directly with the Aging Life Care Professional. If the outcome is unsatisfactory, other options include a local Better Business Bureau, formal Alternative Dispute Resolution organizations or a professional licensing body.

Complainant Contact Information

First Name    
Last Name    
Address      
City    
State Abrev.    
Zip/Postal Code    
Phone Number [### - ### - ####]    
Email    

Aging Life Care Professional's Contact Information (Care Manager)

First Name    
Last Name    
Aging Life Care Professional's Company Name    
Aging Life Care Professionals' Address      
City    
State Abrev.    
Zip/Postal Code    

Details regarding the complaint

Description of the complaint (5,000 characters max)      
What is your relationship to the client?      
What is your relationship with the Aging Life Care Professional (Care Manager)?      
What steps have been taken to resolve this issue? (5,000 characters max)      
The service agreement or contract for services was signed by: (2000 characters max)