Georgia Division of Developmental Disabilities 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 DD Human Rights External Referral 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

Individuals 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.

Hard copy of the DD Human Rights External Referral form and Authorization form, with requests for assistance, may be submitted by mail to:

Developmental Disabilities Human Rights Coordinator

2 Peachtree Street NW, Suite 22-412

Atlanta, GA 30303

Or email to: ddhumanrights@dbhdd.gov

Requester Information

Full name

Mailing Address

City County

State Zip Code

Email Address

Telephone Number

Gender

Female

Male

Are you submitting a complaint/referral on behalf of the individual?

Yes

No

Are you submitting a complaint/referral on behalf of yourself?

Yes

No

Are you the individual’s legal guardian?

Yes

No

Has an informed consent been signed?

Yes

No

Are behavioral efforts in place?

Yes

No

Individual Information

Full Name

Mailing Address

City County

State Zip Code

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*