DFCS Reasonable Modifications and Communication Assistance Request Form for Persons with Disabilities

Do you have a disability and need a reasonable modification or communication assistance to access DFCS services?

To request a reasonable modification, communication assistance, or extra help, please complete the form below. You are not required to complete this form or tell us your disability in order to receive reasonable modifications, communication assistance, or extra help.

Persons with Disabilities Information

Name (required)

Name of the person with a disability who needs a reasonable modification, communication assistance, or extra help.

Date of birth

Client ID

Address

Address 2

City

ZIP/Postal Code

County (required)

Phone Number (required)

Email (if available) (required)

Please check the DFCS program(s) that apply

SNAP/ Food stamps

TANF

Medical Assistance

Medicaid and PeachCare for Kids®

Child welfare

CPS, foster care, adoption, family reunification

Other

Other program

Do you need a reasonable modification because of a disability?

YesNo

If yes, please describe the reasonable modification that you are requesting.

How will this reasonable modification or communication assistance (or extra help) assist you? (required)

Do you need this reasonable modificaton, communication assistance, or extra help:

One timeOngoing

If possible, please explain when and how long you need this assistance (extra help)?

Requester's information

First

Last

Phone Number

Relationship

DFCS Reasonable Modifications and Communication Assistance Request Form for Persons with Disabilities

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Message

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