Child and Family Ombudsman Request for Assistance:

Date of Request:	Click here to enter a date.
Who are you?
Last Name	First Name	Middle Initial
Street Address	Apt. #
City	State	Zip Code
Is your street address the same as your mailing address?	☐Yes ☐No
If no, please provide mailing address to receive mail:
Street Address	Apt.#
City	State	Zip Code
Primary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Secondary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Email Address	Okay to send an email? ☐Yes ☐No

How do you know about this child or family?
☐Child’s Parent ☐Child’s Legal Guardian ☐Child’s Grandparent ☐Other Relative	☐Child ☐Licensed Parent ☐Community Professional or Service Provider ☐Teacher or School Employee
Specify	Specify

☐Child’s Attorney ☐Parent’s Attorney ☐Office of the Public Defender ☐Other Attorney	☐DPHHS Employee ☐Attorney General’s Office ☐County Attorney ☐CASA/GAL
Specify	Specify

☐Law Enforcement Professional	☐Other Relationship
Specify	Specify

Optional Information:

☐African American ☐American Indian or Alaska Native ☐Asian American ☐Native Hawaiian Pacific Islander ☐Hispanic ☐Caucasian ☐Multi-racial	Primary Language:
Are you hearing impaired?	☐Yes or ☐ No
Are you vision impaired?	☐Yes or ☐ No
Do you require interpretation or translation services?	☐Yes or ☐ No
☐Other:

Who is the child? (If more than one child please provide name/age/birth date and gender for each child on additional pages)
Legal Last Name	Legal First Name	Middle Initial
☐Male or ☐Female
Age	Date of Birth (month/day/year)	Sex

Who is the responsible adult where the child lives now?
Last Name	First Name	Relationship to Child
Current Street Address	Apt. #
City	State	Zip Code
Primary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Secondary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Email Address
Does the child have an attorney?	☐ Yes or ☐ No or ☐ Don’t Know
If Yes, attorney’s name if available:	Phone:
Does the child have a Court Appointed Special Advocate (CASA) or a Guardian ad litem (GAL)?	☐ Yes or ☐ No or ☐ Don’t Know
If Yes, CASA/GAL’s name if available:	Phone:

Child’s Optional Information:

☐African American ☐American Indian or Alaska Native ☐Asian American ☐Native Hawaiian Pacific Islander ☐Hispanic ☐Caucasian ☐Multi-racial	Primary Language:
Is the child’s hearing impaired?	☐Yes or ☐ No
Is the child’s vision impaired?	☐Yes or ☐ No
Does the child require interpretation or translation services?	☐Yes or ☐ No
☐Other
If there is more than one child in the family, please include the above information on each child on an attached piece of paper.

Who is the child’s mother?
Last Name	First Name	Middle Initial
Street Address	Apt. #
City	State	Zip Code
Primary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Secondary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Email Address	Okay to send an email? ☐Yes ☐No
Does the mother have an attorney?	☐ Yes or ☐ No or ☐ Don’t Know
If Yes, attorney’s name if available:	Phone:

Mother’s Optional Information:

☐African American ☐American Indian or Alaska Native ☐Asian American ☐Native Hawaiian Pacific Islander ☐Hispanic ☐Caucasian ☐Multi-racial	Primary Language:
Is the mother hearing impaired?	☐Yes or ☐ No
Is the mother vision impaired?	☐Yes or ☐ No
Does the mother require interpretation or translation services?	☐Yes or ☐ No
☐Other:

Who is the child’s father?
Last Name	First Name	Middle Initial
Street Address	Apt. #
City	State	Zip Code
Primary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Secondary Phone	Home/Work/Cell	Okay to leave a message? ☐Yes ☐No
Email Address	Okay to send an email? ☐Yes ☐No
Does the father have an attorney?	☐ Yes or ☐ No or ☐ Don’t Know
If Yes, attorney’s name if available:	Phone:

Father’s Optional Information:

☐African American ☐American Indian or Alaska Native ☐Asian American ☐Native Hawaiian Pacific Islander ☐Hispanic ☐Caucasian ☐Multi-racial	Primary Language:
Is the father hearing impaired?	☐Yes or ☐ No
Is the father vision impaired?	☐Yes or ☐ No
Does the father require interpretation or translation services?	☐Yes or ☐ No
☐Other:

Who is the family’s Child Protection Specialist?
Name	County	Phone Number
Please describe your reason for requesting Ombudsman assistance. Include as much information as you can. What happened? When, where, and who? Also, include names and contact information of other people you think have more information:
Help us understand how the Ombudsman can assist you. Please use additional sheets of paper as needed to explain and give us any paperwork you think will help us understand your concern:
Please tell us everything you have already done about this concern. For example: Have you contacted the Child Protection Specialist? Have you contacted the local supervisor? Have you contacted the Regional Administrator? Please give the name of anyone you have already contacted and tell us what happened so far.
What would you like to see happen for this child or family? What help to you hope to have from the Ombudsman?
How did you hear about the Ombudsman Office?
☐DPHHS Employee	☐Media (TV or radio)
☐Friend	☐Internet
☐Family Member	☐Directory Assistance or Phone Book
☐CASA/GAL	☐CASA/GAL
☐Attorney General’s Office	☐Conference, Training, or Workshop
☐Community Professional or Service Provider	Specify
Specify	☐Other
☐Teacher or School Employee	Specify
Specify

If you have questions about filling out this form or would like help filling out the form, please call the Ombudsman office at 1-844-252-4453 (1-844-25CHILD) or email the Ombudsman at dojombudsman@mt.gov.

Acronyms you might see:
CASA	Court Appointed Special Advocate	DOJ	Department of Justice
GAL	Guardian ad Litem	AG	Attorney General
CPS	Child Protection Specialist	DPHHS	Dept. of Public Health & Human Services
CFSD	Child & Family Services Division