Section 117.APPENDIX B Eligibility determination forms

Section 117.ILLUSTRATION A DMHDD-1237.2, Eligibility Determination – Primary Examiners – Adults with a Severe Mental Illness

Illinois Department of Human Services

ELIGIBLITY DETERMINATION – PRIMARY EXAMINERS

– ADULTS WITH A SEVERE MENTAL ILLNESS

Name of applicant:

Date of examination:

I verify that I am a

board eligible/certified psychiatrist

licensed clinical psychologist

and that the above–named individual was evaluated personally by me.

I verify that I have found the person to meet the eligibility criteria for determination as an Adult with a Severe Mental Illness

I verify that I have found the person does not meet the eligibility criteria for determination as an Adult with a Severe Mental Illness.

I have attached my evaluation and copies of any other evaluations used by me in making this determination.

Name (type or print)

Signature

Address

License no.

Return in self-addressed, stamped envelope or send to:

Department of Human Services

Home-Based Support Services Program

Room 405 Stratton Building

Springfield IL 62765

Section 117.APPENDIX B Eligibility determination forms

Section 117.ILLUSTRATION B DMHDD-1237.2, Eligibility Determination – Primary Examiners – Children with Severe Emotional Disturbance

Illinois Department of Human Services

ELIGIBLITY DETERMINATION – PRIMARY EXAMINERS – CHILDREN WITH A SEVERE EMOTIONAL DISTURBANCE

Name of applicant:
Date of examination:

	I verify that I am a			board eligible/certified psychiatrist
				licensed clinical psychologist
	and that the above–named individual was evaluated personally by me.

	I verify that I have found the person to meet the eligibility criteria for determination as a Child with a Severe Emotional Disturbance.

	I verify that I have found the person does not meet the eligibility criteria for determination as a Child with a Severe Emotional Disturbance.


I have attached my evaluation and copies of any other evaluations used by me in making this determination.
			Name (type or print)
			Signature
			Address


			License no.

Return in self-addressed, stamped envelope or send to:

		Department of Human Services
		Home-Based Support Services Program
		Room 405 Stratton Building
		Springfield IL 62765

Section 117.APPENDIX B Eligibility determination forms

Section 117.ILLUSTRATION C DMHDD-1237.3, Eligibility Determination – Primary Examiners – Children and Adults with Severe Autism

Illinois Department of Human Services

ELIGIBLITY DETERMINATION – PRIMARY EXAMINERS – CHILDREN AND ADULTS WITH A SEVERE AUTISM

Name of applicant:
Date of examination:

	I verify that I am a			board eligible/certified psychiatrist
				licensed clinical psychologist
	and that the above–named individual was evaluated personally by me.

	I verify that I have found the person to meet the eligibility criteria for determination as Children and Adults with a Severe Autism.

	I verify that I have found the person does not meet the eligibility criteria for determination as Children and Adults with a Severe Autism.


I have attached my evaluation and copies of any other evaluations used by me in making this determination.
			Name (type or print)
			Signature
			Address


			License no.

Return in self-addressed, stamped envelope or send to:

		Department of Human Services
		Home-Based Support Services Program
		Room 405 Stratton Building
		Springfield IL 62765

Section 117.ILLUSTRATION D DMHDD-1237.4, Eligibility Determination – Primary Examiners – Children and Adults with Severe or Profound Mental Retardation

Illinois Department of Human Services

ELIGIBLITY DETERMINATION – PRIMARY EXAMINERS – CHILDREN AND ADULTS WITH A SEVERE OR PROFOUND MENTAL RETARDATION

Name of applicant:
Date of examination:

	I verify that I am a			licensed clinical psychologist
				certified school psychologist
	and that the above–named individual was evaluated personally by me.

	I verify that I have found the person to meet the eligibility criteria for determination as Children and Adults with a Severe or Profound Mental Retardation.

	I verify that I have found the person does not meet the eligibility criteria for determination as Children and Adults with a Severe Profound Mental Retardation.


I have attached my evaluation and copies of any other evaluations used by me in making this determination.
			Name (type or print)
			Signature
			Address


			License no.

Return in self-addressed, stamped envelope or send to:

		Department of Human Services
		Home-Based Support Services Program
		Room 405 Stratton Building
		Springfield IL 62765

Section 117.APPENDIX B Eligibility determination forms

Section 117.ILLUSTRATION E DMHDD-1237.5, Eligibility Determination – Primary Examiners for Children and Adults with Severe and Multiple Impairments

Illinois Department of Human Services

ELIGIBLITY DETERMINATION – PRIMARY EXAMINERS – CHILDREN AND ADULTS WITH SEVERE AND MULTIPLE IMPAIRMENTS

Name of applicant:
Date of examination:

	I verify that I am a			board eligible/certified psychiatrist
				licensed clinical psychologist
				licensed physician
	and that the above–named individual was evaluated personally by me.

	I verify that I have found the person to meet the eligibility criteria for determination as Children and Adults with a Severe and Multiple Impairments.

	I verify that I have found the person does not meet the eligibility criteria for determination as Children and Adults with a Severe and Multiple Impairments.


I have attached my evaluation and copies of any other evaluations used by me in making this determination.
			Name (type or print)
			Signature
			Address


			License no.

Return in self-addressed, stamped envelope or send to:

		Department of Human Services
		Home-Based Support Services Program
		Room 405 Stratton Building
		Springfield IL 62765