By checking “I Accept,” I understand and agree that:

• Except as described below or as allowed or required by court order or state or federal law, the information I submit and any other information that is needed to decide if I can receive services will be confidential and will not be shared with anyone else without my permission.
• Information that I submit, which may relate to mental health treatment, substance/alcohol abuse treatment, and HIV status, may be sent to the Department of Social Services (DSS) and may be shared with other state agencies, contractors, or organizations for the purpose of deciding if I can receive services and what services I may need.
• DSS may use my Social Security number, if I provided one, to check my identity and eligibility, and may check it against federal, state, and local government records.
• Submitting this information does not guarantee that I will receive services. I may be asked to provide more information before a decision can be made about whether I can receive services.
• I certify that all information I submit is true and complete to the best of my knowledge. If I knowingly give wrong information, I may be subject to criminal or civil penalty under state or federal law. The information I submit will be checked, and DSS may contact others as needed to help prove that I am eligible.
• I certify that I am submitting this information for:
  • Myself
  • An individual for whom I currently am the court-appointed Conservator of Person or Guardian
  • My minor child
  • An individual whom I am assisting, who has agreed to allow me to submit this information, or who has authorized me to act on their behalf.

Your Right to Make a Discrimination Complaint:
You have the right to make a discrimination complaint if you think we have taken action against you because of your race, color, religion, sex, gender identity or expression, marital status, age, national origin, ancestry, political beliefs, sexual orientation, intellectual disability, mental disability, learning disability, or physical disability, including, but not limited to, blindness.

An individual with a disability may request and receive a reasonable accommodation or special help from the Department of Social Services when it is necessary to allow the individual to have an equal and meaningful opportunity to participate in programs administered by the Department.

If you asked for an accommodation or special help and we refused to provide it, or if you think we have taken action against you based on one of the prohibited reasons listed above, you may make a complaint to the Department’s Affirmative Action Division Director or any of the agencies listed below:

Commissioner of Social Services
Attn: Affirmative Action Division Director/ADA Coordinator
55 Farmington Avenue
Hartford, CT 06105 Phone: 1-860-424-5040
Toll free: 1-800-842-1508
TDD: 1-800-842-4524
Fax: 1-860-424-4948

Connecticut Commission on Human Rights and Opportunities (CHRO)
450 Columbus Boulevard
Hartford, CT 06103-1835 Phone: 860-541-3400
Connecticut Toll Free: 1-800-477-5737
TDD: 860-541-3400
FAX: Please refer to specific Units
Commission on Human Rights and Opportunities (ct.gov)

U.S. Dept. of Health and Human Services
Office for Civil Rights
JFK Federal Building, Room 1875
Boston, MA 02203 Phone: 1-617-565-1340
Toll free: 1-800-368-1019
TDD: 1-800-537-7697
Fax: 1-617-565-3809