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 found in the attachments section of DBHDD Policy #23-100.
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
Full Name Please complete First * Last *
Mailing Address Please complete Street Address *
Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chatooga Chattahoochee Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur Dekalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth N/A City * Please complete County * Please complete
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Email Address * Please complete
Telephone Number * Please complete
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:
Full Name First Last
Mailing Address Street Address
Appling Atkinson Bacon Baker Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Camden Candler Carroll Catoosa Charlton Chatham Chatooga Chattahoochee Cherokee Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Crisp Dade Dawson Decatur Dekalb Dodge Dooly Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie McIntosh Meriwether Miller Mitchell Monroe Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilcox Wilkes Wilkinson Worth City County
Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code
1 2 3 4 5 6 Region
Category of Concerns Choose from this list * Multiple Psychotropic Meds Rights Restriction/Violation Behavior Supports Other
Provider Name (if applicable)
Briefly describe your concerns * Please complete