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Georgia DBHDD Division of Developmental Disabilities (DD)
Human Rights External Referral Form


In order to submit a DD related human rights compliant, violation, or concern to the Human Rights Council (HRC), please complete the following online form. This information will assist in our efforts in determining whether the human rights of an individual receiving developmental disability services are protected. The information you provide will be kept in strict confidence.

Confidentiality
Consumers have the right to confidentiality of their clinical records and treatment information.

If you are a individual, guardian of the person of a individual, parent or court-ordered legal custodian of a minor individual, you can authorize us to access records and treatment information of the individual so that we may assist the individual most fully, by completing and signing the Authorization for Release of Information form.

Paper Forms
If you prefer to fill out paper copies of the DD Human Rights External Referral form and Authorization form, with requests for assistance, you may submit them by mail to:

Developmental Disabilities Human Rights Coordinator
2 Peachtree Street NW, Suite 22-412
Atlanta, GA 30303

Or email: DBHDDhumanrights@dbhdd.ga.gov.

* Required fields

Requester Information

Full Name
   
First *                                            Last *

Mailing Address
 
Street Address *

 
City *                      County *  

 
State *     Zip Code *  

Email Address *
 

Telephone Number *
 

Gender

Are you submitting on behalf of yourself?

Are you submitting on behalf of an individual?

Are you the consumer's legal guardian?

Has an informed consent been signed?

Are behavioral efforts in place?

Does the individual have a developmental disability?

If Yes or Other, please explain:


Individual Information

Full Name
 
First                                               Last

Mailing Address

Street Address

 
City                                                County

 
State                              Zip Code


Region


Category of Concerns
Choose from this list *


Provider Name (if applicable)

Briefly describe your concerns *