Georgia Division of Family and Children Services Youth Rights Grievance Form

Your contact information

Youth Name *

Youth Date of Birth *

Youth Contact Number *

Best Time to Contact *

Name of Placement/Adoptive Family *

Youth Email *

Confirm Youth Email *

Your address

Address *

City *

State *

Zip Code *

County *

DFCS information

DFCS Case Manager *

DFCS Case Manager Contact Number *

Independent Living Specialist *

Additional information

What right do you feel has been violated? Please explain what happened. *

What have you done to resolve this situation/concern prior to filing a STEP ONE of Youth Rights Grievance (INFORMALS)? *

What happened with the outcome during STEP ONE of Youth Rights Grievance process that requires a STEP TWO (If applicable)? *

How would you like this situation/concern to be resolved? *

Social Media

Instagram Profile Link

Twitter Profile Link

Facebook Profile Link

Other (Please Specify)

Please provide contact information for any person who was involved including youth advocate.

Name	Phone Number	Relationship (to youth)
Name *	Phone Number *	Relationship (to youth) *

I hereby certify that the above statements are true and accurate to the best of my knowledge. *

I hereby certify that the above statements are true and accurate to the best of my knowledge.

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