As the victim¹ of a crime allegedly committed by the person named below who is committed to the Department of Behavioral Health and Developmental Disabilities (DBHDD), I would like to receive notifications from DBHDD when the committed person:

• Is discharged from a DBHDD hospital or designated secure facility for competency restoration of juveniles.
• Escapes from such a DBHDD facility.
• Is subsequently readmitted to such a DBHDD facility.

I understand that I will not receive any notifications unless I ask to receive them, by completing and returning the original of this form to the address indicated below. I understand that if my address or telephone number changes in the future, I am responsible for contacting DBHDD at the address or telephone number below to give DBHDD my new address or telephone number.

I understand that this procedure does not entitle me to receive any additional information about the accused person named below. I understand that DBHDD will not inform me of the location or whereabouts of the accused person named below.

If my address or telephone number(s) changes, it is my responsibility to give my new information to:

Director of Forensic Services
Georgia Department of Behavioral Health and Developmental Disabilities
2 Peachtree Street, N.W. Suite 23-493
Atlanta, Georgia 30303
Fax: 770-359-3042
Email: victimnotification@dbhdd.ga.gov
Website: http://dbhdd.georgia.gov

Name of accused person

First
 

 Last
  
 

County where case was tried:
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 Chattahochee Chattooga 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 Fanin 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   

Name of victim

First
  

Last
 
 

Advocate for victim

First
 

Last

Street Address

City
 

State
 

Zip Code

 Email Address:

Phone number:

 

Person to be notified

First
  

Last
 
 

Relationship to victim:
Self Spouse Parent Adult Child Sibling Grandparent Guardian or Custodian Other  
If other, please enter relationship: 

Street Address:
 

City
  

State
  

Zip Code
 

Phone Numbers (provide at least one):
Home

Work

Cell

Signature

By typing my name below, I consent to be notified when the accused person listed above is discharged, escapes, or is readmitted to a DBHDD facility. If my address or telephone number(s) changes, it is my responsibility to give my new information to the DBHDD office listed above.

 

¹ "Victim" means a person against whom a crime has been perpetrated. In the event of the death of the victim, “Victim” will include the following persons (but not if they are the accused person or are in custody for an offense): spouse; adult child if there is no spouse; parent if there is no spouse or adult child; sibling if there is no spouse, adult child or parent; grandparent if there is no spouse, adult child, parent or sibling. If the victim is a minor, the parent, custodian or court appointed guardian may request to receive notifications (but not if he/she is the accused person or is in custody for an offense). If the victim has a guardian appointed in writing by a Judge, the guardian may request to receive notifications (but not if he/she is the accused person or is in custody for an offense). See OCGA § 17-17-3(11).