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Request Help
Request Help
To get help from DD Ombuds, please fill out this form. You can tell us about a concern, make a complaint, or request information and resources. If you need any help filling out this form, please email
[email protected]
.
The DD Ombuds is not an emergency service. If you are experiencing an emergency and need immediate assistance, call 9-1-1.
Are you filling this form out for yourself or someone else?
(Required)
Myself
Someone else
Name
(Required)
Gender
Pronouns
Race/Ethnicity
Preferred Language
Date of birth, age, or estimated age
Address
Phone number
Email
Disability
Do you need an interpreter or other accommodations?
(Required)
Yes
No
What language or accommodations do you need?
(Required)
Information about the person with a developmental disability
Name
(Required)
Gender
Pronouns
Race/Ethnicity
Preferred Language
Date of birth, age, or estimated age
Address
Phone number
Email
Disability
Do they need an interpreter or other accommodations?
(Required)
Yes
No
What language or accommodations do they need?
Information about you
Your name
(Required)
Relationship to person with a developmental disability
Your phone number
Your email
Do you need an interpreter or other accommodations?
(Required)
Yes
No
What language or accommodations do you need?
(Required)
Please describe the concern or complaint
(Required)
When did this issue start?
What do you think will fix the problem?
What would you like DD Ombuds to do? (For example, set up a meeting, three-way call with case manager, provide information and resources, etc.)
Describe any steps you have already taken to fix the concern or complaint
Others Involved
Investigatory agencies (Adult Protective Services, Residential Client Services, Department of Health, etc.)
Case manager or program manager
Guardian
Power of Attorney or Durable Power of Attorney
Family member
Witnesses
Other
Any contact information for them
Do you know of anyone else with a developmental disability affected by this issue?
Making a complaint does not create attorney-client privilege with DD Ombuds. If you need legal help, you should contact an attorney.
Any recommendations about the accessibility of this form should be sent to
[email protected]
.
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