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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