YDHP Referral FormServing youth ages 18-24 in Coshocton, Fairfield, Holmes, Knox, Muskingum, and Licking counties. Young Adult(s) Name First Name Last Name Email (if applicable) Birthday Phone Number Other way we can reach client What county are you seeking services in? Coshocton Fairfield Holmes Knox Licking Muskingum Additional Commenst: Is the client currently known to be pregnant? Yes No Are there any other children in the household? Referring Individual Organization Phone (###) ### #### Email Date of Referral MM DD YYYY Thank you! Our staff will be in contact soon. Client Grievance Form Date MM DD YYYY Name (Filed By) First Name Last Name Name (Filed Against) First Name Last Name Description of the incident (list location, dates, names of witnesses, and names of all parties involved) Signature (type full name) First Name Last Name Date signed/submitted MM DD YYYY Thank you! Our staff will be in contact soon. Client Appeal Form Filed for Termination of Program of Denied Services Date MM DD YYYY Name First Name Last Name Summarize the situation you are appealing; explain why the decision was incorrect, request the outcome you would like, attach any relevant documents and include your contact information. Signature (Type full name) First Name Last Name Thank you!
