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

Name

Name (required)

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

Address of person with disability

Address

Address 2

City

ZIP/Postal Code

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

Do you need a reasonable modification because of a disability? (required)

Yes

No

Do you or your companion need communication assistance because of a disability? If yes, please tell us so that we can assist you. (Select all that apply)

Sign Language interpreter

Cued Speech Interpreter

Oral Interpreter

(Not related to language assistance)

Tactile Interpreter

TTY

Braille

Large Print

Electronic communication

(Email)

Video Relay

Face-to-face interview

Telephone call reminder of program deadlines

Telephonic signature, if applicable

Other

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

One time

Ongoing

Requester's name

First

Last