OFFICIAL COMPLAINT AND REQUEST FOR IMMEDIATE ACTION

Date:__________________

I am filing this official complaint to you and your agency in a plea for help for my child who has been abused or neglected. I want all records and reports relating to my childs abuse that you have filed against the abusers. I am prepared to take any and all administrative and legal actions to protect my child. My child’s State, Federal, Civil and Constitutional Rights are being violated and will lead to severe and permanent harm. Please respond to this complaint within 30 days or less as this harm is life threatening.

MY COMPLAINT CONSISTS OF BUT IS NOT LIMITED TO THE FOLLOWING

CHECK THE ITEMS THAT APPLY

c 1. My child was abused by a police officer, a probation officer, a counselor, or other:

abuser/abusers names________________________________________________________

c 2. My child’s health is being jeopardized due to the poor quality of food and the lack

of proper nutritional supplementation to maintain my child’s health.

c 3. My child’s medical health issues are being neglected.

c 4. My child’s mental health issues are being neglected.

c 5. My child’s educational needs are not being met in the facility

c 6. My child’s rehabilitation needs are not being met in the facility

c 7. My child’s religious and spiritual needs (which are critical in rehabilitation) are not

being met in the facility.

c 8. My child is being isolated and held in solitary confinement, thereby not afforded

the ability to develop healthy and necessary social and interactive skills.

c 9. My child is not receiving proper counseling or rehabilitation in the facility.

c 10. My child’s restricted visitation schedule is obstructing necessary care and

nurturing during the developmental years.

c 11. My child’s entire family and select friends should be allowed the right to visit and

provide emotional support.

c 12. My child’s geographic placement is unacceptable and should provide easier

access for family and friends.

c 13. Other issues

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Complainant:

____________________________ ____________________________ ____________

Print Name Signature Date

Witness:

_______________________________ _______________________________ _____________