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Georgia DBHDD Office of Public Relations

Constituent Services Intake Form


To submit a question, compliment or concern regarding the Department of Behavioral Health and Developmental Disabilities' (DBHDD) services or programs, please complete this intake form. The information will help us accurately identify the nature of your inquiry and help us respond to you in an efficient manner. Provided information will be kept strictly confidential.

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

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

If you are a legislator or legislative aide, we are happy to assist your constituent consumers directly and simply report to you that we have done so, without disclosing confidential information to you. Or if the consumer (or guardian, parent or legal custodian, as appropriate) authorizes disclosure to you, please have that documented by asking them to complete and sign the Authorization for Release of Information form.

Completed and signed Authorization forms, with requests for assistance, can be faxed to us at: 770-408-5439 or scanned and submitted electronically to DBHDDConstituentServices@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 a constituent or consumer?

Are you the consumer's legal guardian?


Constituent / Consumer Information

Full Name
 
First                                               Last

Mailing Address

Street Address

 
City                                                County

 
State                              Zip Code

Personal Information
 
Date of Birth          Social Security No.


Category of Concerns
Choose from this list *


Provider Name (if applicable)

Briefly describe your concerns *