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. NamePhone NumberRelationship (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. Leave this field blank