NEW MEXICO
New Mexico Children, Youth and Families Department
PO Drawer 5160
Santa Fe, New Mexico 87502
Phone 505.827.7602 • Fax 505.827.4053
CYFD RESOURCE FAMILY REQUEST TO FILE GRIEVANCE FORM
Resource Families reserve the right to file a grievance if they witness any policy or procedure violations by PSD staff on their case, when any of
the "Resource Family Bill of Rights" have been violated, or if they are retaliated against. This form shall be used to facilitate a review of the
grievance. This notice must be e-mailed and accompanied by any other letters or documentation that the Resource Family may wish to provide
for review. There are two levels of grievance reviews and must be completed in order. Please identify which level of review below (check one):
Please print clearly (or type) in each of the fields listed below, sign and date. Electronic signatures are permitted.
Your First Name ________________________________
Address ______________________________________________________________________________________________
City __________________________________________ State ______ Zip Code __________________________________
Phone __________________________________
Provider # (if known)
___________________________________________
T
oday’s Date __________________________________
Y
our Signature ___________________________________________
PSD Field County Office & Case Informati
on:
County Office: _______________________________________________________________________________________
Address: ___________________________________________________________________________________________
City __________________________________________
State ______
Zip Code _______________________________
Phone: ___________________________________ Case # (if known): ___________________________________________
Please provide a short description of your grievance and dates of such events:
rev. 12.2020
CYFD RESOURCE FAMILY REQUEST TO FILE GRIEVANCE
Level 1 Review: Office of Constituent Affairs; e-mail: Harry.Montoya@state.nm.us
Level 2 Review: Office of the Inspector General (OIG); email: CYFD-OIG@state.nm.us
Caseworker Name: ____________________________
Caseworker phone: _______________________________________
Please provide a short summary of how you would like to see this grievance resolved:
Your Last Name _________________________________________
