Response

While a phone and email are required to submit a question, concern, or complaint to our team, we understand that folks do not always have these tools. If you do not have an email or phone, please enter a placeholder or N/A in those fields and specify how we can contact you to provide further assistance.

This form should not be used to report suspected child abuse or vulnerable adult abuse.

To report suspected child abuse, please call 1-866-ENDHARM (1-866-363-4276) or refer to Child Protective Services. To contact APS to report allegations of abuse, abandonment, neglect, self-neglect and financial exploitation of vulnerable adults living in the community call, 1-877-734-6277 or report online. Contact RCS to report concerns regarding a person living in a facility (e.g. a nursing home, adult family home, assisted living, enhanced services, intermediate care for individuals with intellectual disabilities) or receiving supported living services call 1-800-562-6078 or report online. For more information about abuse involving vulnerable adults, visit our Report Concerns Involving Vulnerable Adults page.

If you or someone you love are experiencing mental health struggles, emotional distress, alcohol or drug use concerns, or are in a state of mental crisis, please call the National Suicide Prevention Lifeline at 988.

You can reach the Youth Crisis Line by calling Teen Link (866-TEENLINK, or 866-833-6546) or Teen Line (866-714-0090).

Please note: All fields marked with an asterisk (*) are required.

Type of Feedback

Subject

CLIENT or PERSON NEEDING SERVICE (Please note: All fields marked with an asterisk (*) are required.

Prefix

First Name

Middle Name

Last Name

Suffix

ACES Number

Title

Organization

Address Line 1

City

State

Zip

Daytime Phone

Cell Phone

Evening Phone

Date of Birth (Please enter Birthdate in the following format MM/DD/YYYY)

REQUESTOR INFORMATION (if different than above)

Prefix

First Name

Middle Name

Last Name

Suffix

Daytime Phone

Primary/preferred language?

Would you like a response?

PLEASE PROVIDE THE APPLICABLE INFORMATION RELATED TO YOUR CONCERN

Preferred contact method:

*Please note that we are unable to communicate any personal information by email.*

If you selected fax number, please provide.

ADDITIONAL INFORMATION *Use this space to briefly describe the details of your request. Please limit your response to 500 characters.

Please attach supporting documents (PDF, Word or Excel), up to three files and no larger than 15MB each.

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Anyone who requires an auxiliary aid or service for effective communication, or a modification of policies or procedures to participate in a program, service, or activity of DSHS, should contact the specific DSHS program offering the service or activity as soon as possible but no later than 48 hours before the scheduled event. If unable to contact the specific program offering the service or activity, the DSHS-wide ADA Coordinator can assist with routing the request for an accommodation.