• MM slash DD slash YYYY
    If you checked the Medicare. Medicaid, Food Stamps, TANF, and Workman Compensation please provide the information on the following sections.
  • 23. Please select the services that will assist you in becoming more independent.

  • The information contained in this form is true and correct to be the best of my knowledge. Permission is granted to the Independent Living Program to make whatever inquiries might be necessary to verify these statements, so that my IL Coordinator will be able to determine my eligibility for services. In applying for independent living program services, I understand there is a need to collect personal information.

    I understand that consumer service record information concerning me will be kept confidential.

    I understand that I have the opportunity for a timely review of any dissatisfaction with a determination made by the Ability 1st Utah staff concerning the furnishing or denial of Independent Living Services by contacting Sandra Curcio at 801-373-5044.

    I understand that a Client Assistance Program Representative is available to act as my advisor and advocate, and that I may call toll free 1-800-662-9080 or Salt Lake 363-1347 to reach the Disability Law Center / Client Assistance Program (CAP), 205 North 400 West, Salt Lake City, UT 84103.

    I understand that services in this program are provided without regard to sex, race, age, religion, color, or national origin according to Title VI of the Civil Rights Act, and Section 504, Rehab Act of 1973, as amended. The Independent Living Program also assures that no group of individuals will be excluded or found ineligible on the basis of type of disability.

  • Confidentiality Statement

    I understand that what is contained in my case file, as well as, what I divulge to Ability 1st Utah staff is held in the strictest confidence except in the cases listed below:
    1. 1. I can expect you will divulge information to proper individuals, if I exhibit suicidal behavior or extreme suicidal ideation - i.e., if what I do or say leads you to believe, that I may take my life or otherwise harm myself.

    2. 2. I understand you have the obligation to warn the proper individuals if I exhibit tendencies to harm another individual - i.e., you will warn the person who would be harmed, or notify the proper authorities.

    3. 3. I also understand that you are mandated by law to report instances of sexual and/or physical abuse and neglect. This includes instances where I may be the victim, as well as, instances where I might be the perpetrator.

    4. 4. I also understand that it may be necessary to give information to vendors in order to obtain bids for the purpose of completing my goals.

    5. 5. Information may be shared while trying to obtain funding sources - i.e., Utah State Office of Rehabilitation, Utah Assistive Technology Foundation, Medicaid, and Medicare.

    6. 6. In case of emergency, Ability 1st Utah staff may contact:
  • Consumer/Guardian/Representative Signature__________Date

    By typing in your full legal name you agree that this is an electronic signature.