Fillable ADOPTION FACILITATOR COMPLAINT FORM (California)

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ADOPTION FACILITATOR COMPLAINT FORM (California)

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The ADOPTION FACILITATOR COMPLAINT FORM (California) form is 2 pages long and contains:

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File type: PDF

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ADOPTION FACILITATOR COMPLAINT FORM
Complete, sign, and mail this form to the address listed below if you wish to file a complaint against a Registered Adoption Facilitator.
Client Information
First Name: ______________________________________ Middle Initial: _____ Last Name: _________________________________
Street Address: _______________________________________________________________________________________________
City: ________________________________________________________ State: _________________ Zip Code: ________________
Daytime Telephone: ___________________________________ Evening Telephone: ______________________________________
Adoption Facilitator’s Name/Business: _____________________________________________________________________________
Are you a client of the Adoption Facilitator whom you are filing a complaint?
Have you discussed your concerns with the Adoption Facilitator?
□
Yes
□
No
□
Yes
□
No
Did the Adoption Facilitator respond to your complaint?
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Yes
□
No
Date you filed the complaint: __________________________ Date the Adoption Facilitator responded: _________________________
If you received a response from the Adoption Facilitator, please mail the response with this complaint.
Please explain your complaint: (use a separate sheet if necessary)
AD 72 (11/15)
PAGE 1 OF 2
____________________________________________________________
____________________________________________________________ _____________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Have you filed a complaint regarding your concerns with any of the following agencies?
□
Office of the Attorney General
District Attorney’s Office
City Attorney’s Office
Better Business Bureau
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Attach copies of documents related to your complaint such as letters to and responses from the Office of the Attorney General, District
Attorney’s Office, City Attorney’s Office, and/or the Better Business Bureau.
I authorize the California Department of Social Services to provide a copy of this document to the Adoption Facilitator.
SIGNATURE
I declare under penalty of perjury that the statements on this response are true and correct.
SIGNATURE
DATE
Mail or fax this complaint form and all attachments to: California Department of Social Services, Adoptions Services Bureau,
744 P Street, M.S. 8-12-31, Sacramento, CA 95814; FAX: (916) 651-8149
AD 72 (11/15)
PAGE 2 OF 2
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ADOPTION FACILITATOR COMPLAINT FORM (California)

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Completed 2 September 2021

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