DCSD Complaint Form

Suggestion/Complaint Form

Do you have a suggestion to improve the services offered by Delinquency & Court Services Division (DCSD) or want to make a complaint regarding services you received from DCSD, please let us know.

 

Please complete the form and submit it.  The form will go to DCSD’s Quality Assurance Department for follow-up.

 

Today's Date:

 

Person Filing and Association:

 

Parent (Mother):

Parent (Father):

Youth Name:

Date of Birth:

Juvenile ID Number:

Address/ZIP Code:

Phone:

 

Your Association with DCSD (Check one):

 Parent or Caregiver

 Youth

 Provider

 Other

 

Human Service Worker (HSW) Name:  HSW Phone:

HSW Supervisor Name:  HSW Supervisor Phone:

Involved Youth:

Complaint Against:

 

Complaint Details:

Efforts to Resolve:

Resolution Desired:

Person Completing Form:

Title/Role:

Date Form Completed:

 

II(A) Formal (4): It is the policy of the Delinquency and Court Services Division (DCSD) that when the complaint outcome results in a decision adverse to a youth or family, the youth and/or his/her authorized representative will be advised of their right to submit a verbal or written Grievance to the DCSD Quality Assurance Department.  A written grievance may be submitted in any form.

 

 

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