Application for Services


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Employment History

Partner Employment History

Access to Healthcare

Monthly Household Income

Monthly Household Expenses


Housing & Household

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Landlord or Lender

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Confidentiality Statement and Consent to Release Confidential Information

I hereby state that the aforementioned is a complete and accurate representation of my situation. I understand that the Community Resource Center of Teton Valley (CRCTV) has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow CRCTV to release some of my personal information to certain individuals or agencies. I understand that the CRCTV is required by law to report this information to the police if there is evidence of the abuse or neglect of a child, an older adult, or other vulnerable parties; if I present a danger to myself or to others; or if there is a court order that requires disclosure of the information.

Release Authorization

I hereby authorize CRCTV to release any information pertaining to me to the agencies/persons indicated below, and I also authorize the indicated sources to release information/documentation regarding my case to the CRCTV (please provide specific names, as needed):

The duration of this authorization is for one year after the termination of my case. I understand that I may revoke this consent at any time by notifying the facility in writing or orally, except to the extent that action has already been taken in reliance on my consent. A photocopy of this authorization is to be considered as valid as the original document.

I understand that organizations and individuals that are not listed above may be contacted, but that only my general situation and no personal information will be shared with these entities unless I am applying to receive financial assistance of any kind.

If I am applying for financial assistance, I understand that CRCTV may need to speak to relevant agencies and individuals to seek out what resources might be available, to assess which community resources have already been used by me, and to inform those resources of the use of CRCTV funds to prevent duplication of services.

I understand that assistance rendered may not be solely monetary and authorize advocacy on my behalf. I understand that a committee makes the decision as to any assistance that I may receive from CRCTV and CRCTV intake agents do not have authority to, or capacity of, making immediate assistance available.

I have read the disclosure that appears above, I understand what I have read, and by my own will and with full knowledge I sign this document.

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