State of Maryland Foster Youth Ombuds Inquiry Form

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The Maryland Department of Human Services (DHS) helps protect your rights and has appointed a Foster Youth Ombuds to be your personal advocate. Ms. Loney Nguyen (pronounced Ms. Lonnie Win, pronouns She/Hers), your appointed Foster Youth Ombuds, can answer questions or help you resolve a complaint about your foster care case.

Please fill out the form below. This information will provide Ms.Nguyen with important details so that she can better assist you.

The information in this form is confidential and only accessible by the Foster Youth Ombuds.

Please note this office does not take reports of abuse or neglect.You should report suspected abuse or neglect to the local department of social services or to a local law enforcement agency.

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E-Mail-Adresse *

Are you a Youth or Third Party Reporter? *

Are you contacting this office to: *

File a Grievance (Complaint)

Request a Consultation

Youth First and Last Name *

Reporter First and Last Name (If Not Youth)

If you are a third party reporter, does the youth know that you are contacting this office?

Best Phone Number To Reach Youth: *

Best Phone Number to reach reporter *If youth please enter N/A *

Primary Language *

Gender Identity (Youth) *We request this information for the purpose of helping our staff use the most respectful language when addressing you. Information is confidential and only accessible by the Foster Youth Ombudsman *

If Gender Is Not Listed, Please Share

Identified Pronoun (Youth) *We request this information for the purpose of helping our staff use the most respectful language when addressing you. Information is confidential and only accessible by the Foster Youth Ombudsman *

If Pronoun Was Not Listed, Please Share

Is youth currently in care in the State of Maryland? *

County Foster Care Case Is In: *

Case Worker's Name, Phone Number and Email *If unknown please enter IDK *

Have you tried to resolve your concerns by contacting the assigned caseworker or the supervisor? *

Resource Parent (Foster Parent) Name & Phone Number (If this does not apply enter N/A).

Please briefly explain how I can help you? What are your concerns? *

Is your inquiry concerning: (Check all that apply) *

Violation of Youth Rights or Unfair Treatment

Fraud

Complaint Against DSS or Case Worker/Social Worker

Complaint Against Attorney

Complaint Against Resource Parent (Foster Parent)

Complaint Against Program

Safe & Stable Housing

Education & Employment

Wellbeing (Health) & Civic Engagement

Permanent & Supportive Connections

Pflichtfrage

What would you like to see happen? *

Do you give informed consent for the Ombuds to contact the Local Department of Social Services? *

Yes

I need to discuss further

Referral Source: How did you hear about the Foster Youth Ombuds? *

If you were referred by someone, please list who you were referred by and your relationship to the person:

Sie erhalten unter der von Ihnen angegebenen E-Mail-Adresse eine Kopie Ihrer Antworten.

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