Arizona Department of Health Services (ADHS) – Division of Licensing Services

Formal Health Care Institution Licensing Complaint

Respondent: The Guidance Center (TGC), Flagstaff, Arizona
Complainant: Malene Comes, Founder of Between Trust and Trauma
Date of Filing: Friday, August 21, 2026

I. Introduction & Statement of Regulatory Concern

This complaint is formally filed against The Guidance Center (TGC) and requests investigation of potential systemic failures to comply with Arizona administrative rules governing patient rights, personnel competency, behavioral health services, informed consent, and medical records.

TGC, in partnership with Flagstaff Shelter Services and Northern Arizona University (NAU), has recently deployed an outreach, data-tracking, and psychiatric referral/intake program inside the Huntington Drive emergency wet shelter.

On August 10, 2026, a formal public stakeholder inquiry was delivered to TGC leadership requesting verification of basic safeguards surrounding this program. TGC administration has not provided answers regarding personnel qualifications, training, informed-consent procedures, data collection, or the circumstances under which individuals encountered at the shelter may be transported or referred to TGC crisis or inpatient services.

Because TGC operates licensed behavioral-health services involving an exceptionally vulnerable population, I am requesting that ADHS independently determine whether this program complies with Arizona health-care institution licensing requirements.

Specifically, I request review of personnel files, credentials, training records, policies governing assessment and referral, patient-rights procedures, informed-consent documentation, medical-record creation and access, and any policies governing information collected through the program and subsequently provided to or accessed by outside partners.

II. Personnel Qualifications & Staff Competency

A.A.C. R9-10-1006 — Personnel

TGC publicly represents that “licensed” mental-health professionals staff its shelter outreach teams. However, TGC has not identified the professional credentials or scope of practice of the personnel actually performing these functions.

The program potentially involves encounters with individuals experiencing suicidality, substance intoxication, psychiatric crisis, severe trauma, or other conditions requiring substantial clinical judgment.

I therefore request that ADHS determine:

• The professional credentials and classifications of personnel assigned to the shelter program;
• Whether, and to what extent, Behavioral Health Technicians, interns, trainees, or other personnel are participating;
• What clinical functions each category of personnel is permitted to perform;
• Whether personnel are performing duties consistent with their qualifications and scope;
• Whether required supervision is actually being provided; and
• Whether TGC maintains the personnel documentation required by Arizona licensing regulations.

III. Training and Competency for a High-Risk Population

A.A.C. R9-10-1006 — Personnel; R9-10-1011 — Behavioral Health Services

TGC has not disclosed whether personnel assigned to the Huntington Drive shelter have received substantive training appropriate to the population and functions involved.

Of particular concern are competencies involving:

• Evidence-based suicide assessment;
• Trauma-informed care;
• Crisis intervention;
• De-escalation;
• Prevention of retraumatization;
• Assessment of individuals affected by alcohol or other substances;
• Recognition of medical versus psychiatric emergencies;
• Patient rights and voluntary decision-making; and
• Appropriate criteria for referral or escalation to higher levels of behavioral-health care.

I request that ADHS inspect TGC’s training records, competency documentation, supervision structure, and applicable policies and determine whether personnel deployed through this program have been appropriately trained and evaluated for the duties they are performing.

IV. Patient Rights, Consent, Referral and Potential Coercion

A.A.C. R9-10-1008 — Patient Rights; R9-10-1011 — Behavioral Health Services; and, where applicable, R9-10-1012 — Behavioral Health Observation/Stabilization Services

The population served by Flagstaff Shelter Services includes individuals who may be experiencing homelessness, severe psychological distress, intoxication, trauma, cognitive impairment, sleep deprivation, medical illness, or other circumstances potentially affecting their ability to understand and freely consent to behavioral-health intervention.

TGC has not explained what safeguards distinguish voluntary outreach and referral from coercive intervention, nor what procedures govern assessment of an individual’s ability to make informed decisions.

This raises particular concern because the program creates a direct pathway from an emergency shelter into TGC’s own behavioral-health services, including crisis and potentially inpatient services.

I request that ADHS determine:

• How individuals are informed that participation in behavioral-health assessment or referral is voluntary, when applicable;
• How refusal is documented and respected;
• What criteria personnel use to determine that emergency or involuntary intervention is warranted;
• How capacity and impairment are evaluated when an individual is intoxicated or otherwise compromised;
• Whether individuals are informed of alternatives to TGC services;
• Whether shelter access, housing services, food, or other necessities are in any way conditioned upon participation;
• How patient-rights requirements are communicated and documented; and
• Whether referrals, transports, observation/stabilization admissions, or other escalations comply with applicable Arizona requirements.

V. Medical Records, Data Collection, Access & Third-Party Use

A.A.C. R9-10-1009 — Medical Records

This program has been publicly described as involving a data component in cooperation with Northern Arizona University. I have separately raised concerns with NAU regarding the nature of that data collection and whether its activities constitute research, program evaluation, or another form of data analysis.

My concern for ADHS purposes is narrower and directly related to TGC’s obligations as a licensed health-care institution.

I am requesting investigation into whether information collected during shelter encounters results in the creation of TGC patient or medical records; who is authorized to access those records; what information is subsequently shared with NAU, Flagstaff Shelter Services, or other third parties; and what consent or other lawful authorization supports such access or disclosure.

Specifically, I request that ADHS determine:

• At what point an encounter at the shelter results in creation of a TGC medical record;
• What information is entered into that record;
• Who has access to records created through the program;
• Whether shelter personnel, NAU personnel, researchers, students, contractors, or other third parties have direct or indirect access to identifiable patient information;
• Whether data supplied to NAU is identifiable, coded, de-identified, or aggregated;
• What consent or authorization is obtained before information is collected or disclosed;
• Whether refusal to participate in data collection affects access to shelter or behavioral-health services;
• Whether disclosures and access are documented as required; and
• Whether TGC’s medical-record policies and actual practices comply with R9-10-1009 and other applicable state requirements.

The involvement of an outside university makes clarity regarding the boundary between clinical records, program data, and research or evaluation data particularly important.

VI. Administration, Oversight & Potential Financial Conflict

A.A.C. R9-10-1003 — Administration

TGC operates both the outreach/referral mechanism and behavioral-health services into which individuals encountered through the shelter program may subsequently be referred.

Public financial records also indicate that TGC has experienced substantial financial pressure.

I am not asking ADHS to infer financial misconduct from those facts alone. I am asking ADHS to examine whether this organizational structure creates incentives that are adequately controlled through clinical policies, supervision, patient-rights protections, and appropriate admission/referral criteria.

In particular, ADHS should determine whether decisions to escalate individuals from shelter outreach into TGC crisis, observation/stabilization, inpatient, substance-use, or other reimbursable services are based upon documented clinical criteria rather than institutional financial interests.

VII. Conclusion & Formal Request for Action

The Guidance Center’s refusal to provide meaningful transparency regarding this program leaves fundamental regulatory questions unanswered.

I therefore formally request that ADHS conduct an investigation, including an unannounced on-site survey if appropriate, addressing:

1. Personnel credentials and scope of practice;
2. Training and competency records;
3. Suicide-assessment and crisis-intervention protocols;
4. Patient-rights and informed-consent procedures;
5. Criteria governing voluntary and involuntary referrals, transports, and admissions;
6. Medical-record creation and access;
7. Data sharing involving Flagstaff Shelter Services, Northern Arizona University, or other third parties;
8. Policies protecting individuals who decline assessment, referral, treatment, or data participation; and
9. Whether TGC’s clinical referral practices through this program comply with applicable Arizona health-care institution licensing requirements.

The individuals encountered through this program may be among the most vulnerable people in Northern Arizona. The combination of homelessness, psychiatric distress, substance use, potential impairment, institutional data collection, and direct access to higher-acuity psychiatric services warrants meaningful regulatory scrutiny.

I respectfully request that ADHS determine whether the safeguards required by Arizona law actually exist and are being followed.