• Information & Referral Request Form

    Yellowstone Country Assistance Network (YCAN)Serves individuals and households who: Live in Park County, WY, Live in Hot Springs County, WY, Live or work in Teton County, WY.

  • If you need in-person application assistance, please let us know below so we can identify the right referral or next step. YCAN will review eligibility, maintain your file, and coordinate next steps as appropriate.

  • About You

  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Way to Contact You*
  • Safe to Leave Voicemail?*
  • Safe to Text?*

  • Service Area Eligibility

  • Which county applies to you?*
  • YCAN only serves Park County, Hot Springs County, and people who live or work in Teton County, Wyoming. Please contact Wyoming 211 for help in your area.
  • Are you seeking information only, or were you referred for eligibility processing/support?*
  • Do you need a referral for in-person application assistance?*
  • Were you referred by a provider, program, or partner agency?*

  • What You Need Help With

  • What are you contacting YCAN about today?*
  • Is this request urgent?*
  • Have you already contacted any agencies or programs about this issue?*

  • Household / Situation Details

  • Who is this request for?*
  • Special circumstances

  • Follow-Up

  • Best days to reach you
  • Best time to reach you
  • What do you want help with?*

  • Human Verification and Consent

    I understand this form is an information and referral request, not an application for services. I understand YCAN is a connected processing and coordination center, not a front-line direct service provider, and may help gather information, review eligibility, maintain files, coordinate next steps, and forward approved requests for payment processing. I understand YCAN does not issue payments internally
  • *
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: