Disclosure (Please initial)
Disclosure (Please initial)
Disclosure (Please initial)
(Signature of Applicant or Applicants)
Disclosure (Please initial each line):
Disclosure (Please initial each line):
(Signature of Applicant or Applicants)

Household Information

Please List ALL family members, including adults:

Employment History (Please fill out in detail for all adults over 18 in the household)

Client Statement

(Please be as specific and thorough as possible. This is your chance to tell your story and to provide us with enough information to best understand your crisis.)
Client Statement

Release of Information

In order for YCC to coordinate resources that would best benefit you, it is sometimes necessary to communicate both within YCC Centers, as well as with other community agencies, regarding your case. I give permission to allow my information to be shared with local community agencies or programs that may have a connection to my case, for the purpose of tracking, supporting, and coordinating services. I also give permission for those agencies to communicate with the YCC regarding my case.

Agency Names

Department of Work Force Services - Department of Child and Family Services - Catholic Community Services - Salvation Army - Cottages of Hope - Davis Housing Authority - Midtown Medical Clinic - St. Anne's Lantern House - Homeless Veterans Fellowship - Ogden Rescue Mission - Ogden Housing Authority - Weber Housing Authority

Exceptions to Confidentiality/Release of Information to Other

1. Threats to harm yourself or others 2. Abuse or neglect of a child 3. Court subpoenaed files
Client Signature

YCC TANF Referral Form