YOUTH IN CARE – REQUIRED INTAKE INFORMATION Malan's Peak
Student Name *
Caseworker/Manager Name *
I certify that the student named in this document is in the legal custody of or receiving services from the UtahDepartment of Human Services (DCFS, JJS) or an equivalent agency of a Native American tribe
Caseworker/Manger Signature *
Caseworker/Manger Signature Date *
MM
/
DD
/
YYYY
Caseworker/Manager Email *
Caseworker/Manager Cell Number *
Caseworker/Manager Office Number *
Agency *
Caseworker/Manager Address *
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