Section 117.100  Purpose

 

a)         The purpose of the Home-Based Support Services Law for Mentally Disabled Adults [405 ILCS 80/2-1] is to authorize the Department to encourage, develop, sponsor and fund home-based and community-based services for adults who are mentally disabled in order to provide alternatives to institutionalization and to permit them to remain in their own homes (Section 2-2 of the Home-Based Support Services Law).

 

b)         The purpose of the Family Assistance Law for Mentally Disabled Children [405 ILCS 80/3-1] is to create a mandate for the Department to strengthen and promote families who provide care within the family home for children whose level of mental illness or developmental disability constitutes a risk of out-of-home placement.  It is intended to strengthen, promote and empower families to determine the most appropriate use of resources to address the unique and changing needs of those families' mentally disabled children (Section 3-2 of the Family Assistance Law).

 

Section 117.110  Incorporation by reference

 

Any rules of an agency of the United States or of a nationally-recognized organization or association that are incorporated by reference in this Part are incorporated as of the date specified, and do not include any later amendments or editions.

 

Section 117.115  Principles

 

a)         Individuals and their families or legal guardians shall select the needed supports and services.

 

b)         Individuals shall live in homes of their choosing in communities with or near family and friends and other individuals who are important to them.

 

c)         Services shall be designed as described in Subparts B and C of this Part and provided to enhance the individual's existing natural social support network of family, friends, and acquaintances within the larger community of persons without disabilities, as well as social contacts among peers and paid caregivers.

 

d)         Individuals and their families or legal guardians shall be permitted to experience decision-making and risk in order to enhance personal growth.

 

e)         Individuals shall not be obligated to participate in a particular training program or activity because it is part of the program structure or for the convinence of staff.

 

f)         The type, intensity and source of support services shall vary according to the individual's needs, other supports available and personal preferences, shall promote community integration, independence and self-sufficiency, and shall change as the individual's needs and preferences change.

 

g)         Training and assistance shall be provided to the extent possible in natural environments during the course of a normal day.  This includes participating in general community life, school, work and leisure activities and accessing general community goods and services, rather than participating primarily or only within the service system with other persons with disabilities and paid caregivers.

 

h)         The values of integration, individuality, personal choice and skill enhancement shall also encompass health, leisure and recreational activities, social services and education, as well as family and home-based supports.

 

i)          Use of generic (non-disability) community resources such as church, Y.M.C.A., Y.W.C.A., educational, clubs, shopping and recreation shall be preferred over segregated programs for special populations, to the extent consistent with the needs of the individual and family.  However, if it is difficult for the individual to use generic resources without support, support tailored to the individual's needs shall be offered.

 

j)          Family support must focus on the family unit.  Family support should be broadly defined so as to respond to the needs of all members of the family, including the individual with a developmental or mental disability, parents, siblings, and other extended family members living within the household.

 

Section 117.120  Definitions

 

Unless the context otherwise requires, the terms used in this Part have the meanings ascribed to them in this Section.

 

            "Abuse."  Any physical injury, sexual abuse or mental injury inflicted on an individual other than by accidental means (Section 1-101.1 of the Code).

 

            Physical injury includes all injuries serious enough to require immediate medical treatment by a physician, such as fractures and lacerations which require suturing and all other injuries which because of the circumstances or nature of the injury indicate possible abuse or neglect;

 

            Sexual abuse includes but is not limited to any sexual penetration or sexual conduct between an individual and other person if the individual has been adjudicated legally disabled, or has a guardian, or is unable to understand the nature of the act or is unable to give knowing consent, or is injured, or alleges that there is, or there is evidence of, use of force, coercion, or the exchange of money or anything of value; and

 

            Mental injury includes use of words, signs, gestures or other actions by anyone against an individual which intimidates, demeans, harasses, causes emotional anguish or distress, ridicules, threatens, harms or shall knowingly incite or precipitate maladaptive behavior on the part of an individual. Mental injury also includes exploitation, which is any act that uses individuals, their resources or their possessions for an agency employee's personal gain or for an agency's benefit.

 

            "Act."  The Mental Health and Developmental Disabilities Confidentiality Act [740 ILCS 110].

 

            "Adult."  A person between the ages of 18 and 60 years, inclusive.

 

            "Agency."  A community mental health or developmental services organization which is a sole proprietorship, association, partnership, corporation or organization, public or private, either for profit or not for profit.

 

            "Autism."  A lifelong developmental disability which is manifested by a combination of significant disturbances in intellectual, sensory, cognitive, social, psychological, and emotional functioning and is distinguished from other related disorders by impaired or disordered language and communication; failure to develop appropriate social relationships; ritualistic or compulsive behaviors.

 

            "Cerebral palsy."  A disorder dating from birth or early infancy, non-progressive, characterized by absence or aberrations of motor function (paralysis, weakness, incoordination) and of the other manifestations of organic brain damage such as sensory disorder, seizures, mental retardation, learning difficulty and behavior disorders

 

            "Child."  A person who is 17 years old or younger.

 

            "Code."  The Mental Health and Developmental Disabilities Code [405 ILCS 5].

 

            "Crisis management."  Emergency services of an intensive nature to alleviate stressful situations.

 

            "Day."  A calendar day unless otherwise specified.

 

            "Department."  The Department of Human Services.

 

            "Department-funded out-of-home placement services."  Those services for which the Department pays the partial or full cost of care of the residential placement.

 

            "Developmental disability."  Disability which is attributable to mental retardation, cerebral palsy, epilepsy or autism; or to any other condition which results in impairment similar to that caused by mental retardation and which requires services similar to those required by a mentally retarded person.  Such disability must originate before the age of 18 years, be expected to continue indefinitely, and constitute a substantial handicap (Section 1-106 of the Code).

 

            "Developmentally disabled."  Having a developmental disability.

 

            "DSM-III-R."  The Diagnostic and Statistical Manual of Mental Disorders, Third Edition, revised (DMS-III-R, American Psychiatric Association, 1987 edition).

 

            "Employment-related services."  Services which allow an individual to participate in employment or which prepare an individual for future participation in employment.

 

            "Epilepsy."  A chronic disorder of the brain which is categorized by the tendency to have recurrent seizures.  Seizures are sudden, uncontrolled episodes of excessive electrical discharges of brain cells with associated sensory, motor and/or behavioral changes.

 

            "Family."  The spouse and children and the parent or parent substitute, as defined by this Section, sister, and brother of an individual.

 

            "Family Assistance Law."  The Family Assistance Law for Mentally Disabled Children [405 ILCS 80/3-1].

 

            "Goal."  An expected result or condition that involves a specified period of time to achieve, that is specified in behavioral terms in a statement of relatively broad scope, and that provides guidance in establishing specific objectives directed toward its attainment.

 

            "Habilitation."  An effort directed toward the remediation of a disability or toward increasing an individual's level of physical, mental, social or economic functioning, independence and self-respect.  Habilitation may include, but is not limited to, diagnosis, evaluation, medical services, residential care, day care, special living arrangements, training, education, sheltered employment, protective services, counseling and other services through interaction and participation in the community (Section 1-111 of the Code).

 

            "Home-based services."  Services provided to a mentally disabled adult who lives in his or her own home.  These services may include but are not limited to:  home health services, service facilitation, crisis management, training and assistance in self-care, personal care services, habilitation and rehabilitation services, employment-related services, respite care, and other skill training that enables a person to become self-supporting (Section 2-3 of the Home-Base Support Services Law).

 

            "Home-Based Support Services Law."  The Home-Based Support Services Law for Mentally Disabled Adults [405 ILCS 80/2-1].

 

            "Illinois resident."  an individual legally admitted to the United States who lives in Illinois, and has no present intention to move from Illinois.

 

            "Individual" or "individuals."  A person or persons who receives or receive services or support as described in this Part.

 

            "Informed consent."  Permission voluntarily granted by the individual or guardian for the release of information, for participation in the program services specified in the service/treatment plan or for the use of a specific procedure in the plan. Informed consent means full disclosure to the individual or guardian of the information required for him or her to make the decision intelligently.

 

            "Legal guardian."  The court-appointed guardian or conservator of the person (Section 1-110 of the Code).

 

            "Licensed Clinical Psychologist."  A clinical psychologist licensed by the Clinical Psychologist Licensing Act [225 ILCS 15].

 

            "Mental disability."  A developmental disability, a mental illness in an adult or an emotional disturbance in a child.

 

            "Mentally disabled adult."  A person between the ages of 18 and 60 years who lives in his or her own home; who needs home-based services, but does not require 24-hour-a-day supervision; and who has one of the following conditions:  severe autism, severe mental illness, severe or profound mental retardation, or severe and multiple impairments (Section 2-3 of the Home-Based Support Services Law).

 

            "Mental retardation."  Significantly subaverage general intellectual functioning which exists concurrently with impairment in adaptive behavior and which originates before the age of 18 years (Section 1-116 of the Code).

 

            "Natural support network."  a social circle affiliated with an individual that may include, but is not limited to, family members, friends, co-workers and peers.

 

            "Neglect."  Failure to provide adequate medical or personal care or maintenance to an individual, which failure results in physical or mental injury to an individual or in the deterioration of the individual's physical or mental condition (Section 1-117.1 of the Code).

 

            "Objective."  An expected result or condition that involves a specified period of time to achieve, that is specified in behavioral terms and that is related to the achievement of a goal.

 

            "Own home."  In one's "own home" means that a mentally disabled adult lives alone; or that a mentally disabled adult is in full-time residence with his or her parents, legal guardian, or other relatives; or that a mentally disabled adult is in full-time residence in a setting not subject to licensure under the Nursing Home Care Act [210 ILCS 45] or the Child Care Act of 1969 [225 ILCS 10], with three or fewer other adults unrelated to the mentally disabled adult who do not provide home-based services to the mentally disabled adult.  (Section 2-3 of the Home-Based Support Services Law).

 

            "Parent" or "parent substitute."  A person acting in the capacity of a parent with respect to an individual with mental disabilities who is 17 years old or younger.  The parent shall be:

 

            The legal guardian, if a legal guardian has been determined;

 

            The natural or adoptive parent, if no legal guardian has been determined;

 

            A person licensed as a foster parent and providing care under the Child Care Act of 1969; or

 

            Another relative who is 21 years old or older who has a parent-like relationship with the individual with mental disabilities and who wishes to serve as the parent substitute.  This relative shall be considered the parent for purposes of this Part if there is no objection from:

 

            The individual;

 

            The legal guardian, if a legal guardian has been determined; or

 

            The natural or adoptive parent, if no legal guardian has been determined.

 

            "Primary examiner."  The licensed clinical psychologist and/or psychiatrist and/or physician asked to conduct an evaluation to determine whether an individual applying for programs under this Part meets the criteria for severe level of disability.

 

            "Provider agency." (See "Agency.")

 

            "Random selection."  To ensure equal opportunity to the programs described in this Part, the Department shall use a random selection process.  The selection process shall be implemented in the following manner:  children and adults shall be selected separately, based on two programs and two line item appropriations; residents from each region of the State shall be selected in proportion to the population of that region; an equal number of adults with a developmental disability and mental illness shall be selected; and an equal number of children with a developmental disability and an emotional disturbance shall be selected.  There shall be four pools within each region:  children with an emotional disturbance; children with a developmental disability; adults with mental illness; adults with a developmental disability.  Within each of the separate pools of applicants identified above, a computer shall randomly number all preliminary applications from one through the number of applications within that pool.  The proper number of persons to be enrolled from each pool shall be chosen according to the per capita approach described above.  This number of people (number one through the maximum permitted for each pool) shall be chosen as provisional participants.  The provisional participants shall be requested to verify eligibility criteria and diagnosis through evaluation.  If any provisional applicant is found ineligible, or for any other reason fails to enter the program, the next alternate based on the sequential numbering shall be selected for enrollment after undergoing verification of eligibility and diagnosis through evaluation.

 

            "Region."  A service division of the State created by the Department in accordance with Section 8 of the Mental Health and Developmental Disabilities Administrative Act [20 ILCS 1705/8].

 

            "Rehabilitation."  An effort toward the amelioration of a disability or toward restoring an individual's level of physical, mental, social or economic functioning, independence and self-respect.

 

            "Relative."  A person having any of the following relationships by blood, marriage or adoption:  parent, son, daughter, brother, sister, grandparent, uncle, aunt, nephew, niece, great grandparent, great uncle, great aunt, stepbrother, stepson, stepdaughter, stepparent or first cousin (Section 2-3 of the Home-Based Support Services Law).

 

            "Secretary."  The Secretary of the Department of Human Services or his or her designee.

 

            "Service facilitation."  Assisting an adult individual participating in the Home-Based Support program with the development and modification of a service/treatment plan, helping the individual gain access to the services identified in the plan, and advocating on the individual's behalf if services are not being provided as prescribed in the plan or assisting a family participating in the Family Assistance Program in determining the most appropriate use of resources to address the needs of the child with a severe mental disability within the context of the family.  Assisting families also includes providing information about local support services, locating, advocating for or creating services that conform to the individual family's desires.

 

            "Service facilitator."  An agency representative with experience in working with mentally disabled persons and who provides service facilitation.

 

            "Service/treatment plan" or "plan."  The basis on which services shall be planned by the individual, a service facilitator and other persons chosen by the individual, provided by a service agency, an organization, or an individual and reimbursed by the Department for purposes of the Home-Based Support Services Program.

 

            "Services."  Services which are rendered and are partially or wholly funded by the Department.

 

            "Severe autism."  A lifelong developmental disability which is typically manifested before 30 months of age and is characterized by disturbances in the rate and sequences of cognitive, affective, psychomotor, language and speech development.  A person shall be determined severely autistic, for purposes of this Part, if he or she manifests all of the following characteristics:  disturbance in the capacity to relate appropriately to people, events and objects; absence, disorder or delay of language; speech or meaningful communication; unusual or inconsistent response to sensory stimuli in one or more of the following:  sight, hearing, touch, pain, balance, smell, taste, or the way the person holds his or her body; and insistence on sameness as shown by stereotyped or repetitive behavioral patterns, repetitive movements, abnormal preoccupation, or resistance to change.  There shall be an absence of the characteristics associated with schizophrenia, such as delusions, hallucinations, loosening of associations and incoherence. (Section 2-3 of the Home-Based Support Services Law and Section 3-3 of the Family Assistance Law)

 

            "Severe emotional disturbance."  A child with a severe emotional disturbance is one who, on the basis of a psychosis or other emotional or behavioral disorder, suffers from severe disability which requires sustained treatment interventions for a year or more, and which generally requires attention from two or more agencies.

 

            "Severe mental illness."  The manifestation of both the following characteristics:  the presence of a major mental disorder in adults, or a mental disorder in children or adolescents, classified in the DSM-III-R, excluding alcohol or substance abuse, Alzheimer's disease, or other forms of dementia based upon organic or physical disorders; and a functional disability of an extended duration for adults, or any duration for children or adolescents, which results in substantial limitations in major life activities. (Section 2-3 of the Home-Based Support Services Law and Section 3-3 of the Family Assistance Law)

 

            "Severe or profound mental retardation."  The manifestation of all of the following characteristics: development at a rate approximately four and one-half or more standard deviations below the mean as determined through intellectual assessment; lack of development primarily in the cognitive domain; and impairment of adaptive behavior. This impairment constitutes a substantial disability and can be expected to continue indefinitely.  (Section 2-3 of the Home-Based Support Services Law and Section 3-3 of the Family Assistance Law)

 

            "Severe and multiple impairments."  The manifestation of all the following characteristics: multiple handicaps in the physical, sensory, behavioral or cognitive domains which constitute a severe or profound handicap; development at substantially less than expected rate for the age group in the cognitive, affective or psychomotor domains; and a diagnosis of a developmental disability as defined in Section 1-106 of the Code. (Section 2-3 of the Home-Based Support Services Law and Section 3-3 of the Family Assistance Law)

 

            "Skills training."  Services aimed at improving an individual's ability to perform the activities of daily living and/or community living and/or work-related proficiencies.

 

            "Special education program."  Specially designed instruction, at no cost to the parent or individual, to meet the unique needs of an individual with a disability up to age 21, including classroom instruction, instruction in physical education, home instruction and instruction in hospitals and institutions (Education for the Handicapped Act (20 U.S.C.A. 1400 (1996)) and the rules of the State Board of Education at 23 Ill. Adm. Code 226).

 

            "Substantial disability."  A physical and mental disability, resulting from mental retardation, cerebral palsy, epilepsy, or autism, of such severity that, alone or in connection with social, legal, or economic constraints, it requires the provision of specialized services over an extended period of time directed toward the individual's social, personal or economic habilitation or rehabilitation.

 

            "Supported employment."  Competitive work in integrated work settings for incidivuals with severe mental disabilities for whom competitive employment has not traditionally occurred or for individuals for whom competitive employment has been interrupted or intermittent as a result of a severe disability and who need ongoing support services to perform such work.

 

            "Twenty-four-hour-a-day-supervision."  Care by a trained mental health or developmental disability professional on an ongoing basis (Section 2-3 of the Home-Based Support Services Law).

 

Section 117.125  Individuals' records and informed consent

 

a)         The individual or guardian shall give informed consent for the release of information and to participate in the services specified in the service/treatment plan, which shall be documented in the individual's case record.

 

b)         The Department shall maintain a roster of all applicants who have been chosen and have been determined eligible for the programs described in this Part.

 

c)         The Department shall maintain a permanent case record for each individual who has been chosen and determined eligible.  Control and protection of the record shall be governed by the Act.

 

d)         Department staff shall maintain a continuous, chronological record of all activities and events in the case records.  Events and activities shall be documented in a standard format with sufficient specificity that progress can be monitored by an uninformed reviewer without additional information from responsible staff.

 

e)         Department-designated agencies shall also maintain a case record for each individual served.  Control and protection of the records shall be governed by the Act.

 

Section 117.130  Outreach plan

 

Annually, information shall be disseminated by the Department in English and in Spanish to individuals who may be eligible for the programs described in this Part, and to persons who have contact with individuals who may be eligible to participate in these programs.  Furthermore, all developmental disability and mental health agencies, service facilitation units and other service organizations shall be sent brochures containing preliminary application forms (117.Appendix A) for distribution to potentially-eligible individuals.  The Department shall diseminate letters explaining the programs to agencies and advocacy organizations around the State.

 

Section 117.135  Preliminary application process

 

a)         The Department shall disseminate preliminary applications in English and Spanish annually to those individuals who may be eligible to participate in the programs described in this Part.

 

b)         Applicants shall submit their completed preliminary applications to the Department, 405 Stratton Building, Springfield, IL 62765 annually by a date determined by the Department, but no later than July 31.

 

c)         Preliminary application for the Home-Based Support Services Program, described in Subpart B (form DMHDD-1235), must be made by the individual or his or her guardian.  Preliminary application for the Family Assistance Program, described in Subpart C (form DMHDD-1236), must be made by the child's parent. The applicant is responsible for providing complete and accurate information as specified in the application package and instructions (see Section 117.Appendix B, Illustrations A and B).

 

d)         Individuals shall be chosen through a random selection process as described in Section 117.120.  The number of individuals chosen to participate in these programs shall be contingent upon the availability of funds appropriated by the General Assembly for these purposes.  The Department shall notify individuals in writing of their selection within 30 days after final approval of the application.  In each year in which funds are available for expanded enrollment, the Department shall conduct a random selection process and select additional individuals for these programs.

 

Section 117.140  Application and eligibility determination process

 

a)         The Department shall send and ask applicants chosen through the random selection process to complete an application package (described in subsection (b) of this Section) within 30 days after being notified that they have been chosen.

 

b)         The application package shall include:  

 

1)         A letter explaining the Department's eligibility verification process;

 

2)         Instructions for submitting the necessary clinical information to verify the severity of the disability and other eligibility criteria;

 

3)         A listing of Department-designated agencies in the applicant's region which may assist with verification of disability;

 

4)         Written instructions to the primary examiners on what they must do to verify eligibility;

 

5)         Eligibility criteria for individuals with severe mental illness or emotional disturbance, severe autism, severe mental retardation and severe and multiple impairments; and

 

6)         Eligibility determination forms that must be signed by the primary examiner (see Section 117.Appendix B).

 

c)         Documentation of a severe or profound mental retardation shall be based on a comprehensive documented evaluation by a licensed clinical psychologist or a certified school psychologist for children or for adults up to the age of 21 sho are in a special education program.  The evaluation shall verify that the individual's severe or profound mental retardation originated before the age of 18 and has resulted in significantly subaverage general intellectual functioning in concurrence with impairment in adaptive behavior and meets the Classification in Mental Retardation (American Association on Mental Retardation, 1983 edition) or the DSM-III-R criteria of severe or profound mental retardation, i.e., an intelligence quotient (I.Q.) of 40 or below, and a severe or profound level of adaptive behavior in keeping with illustrations in the Classification in Mental Retardation.

 

d)         Documentation of a severe mental illness shall be based on a comprehensive documented evaluation by a licensed clinical psychologist or psychiatrist.  The evaluation shall verify that the individual's primary diagnosis meets one of the DSM-III-R major mental disorders listed below (such diagnosis may coexist with other DSM-III-R diagnoses in Axis I or other areas):  schizophrenic disorder; delusional disorder; schizoaffective disorder; bipolaraffective disorder; atypical psychosis; or major depression, recurrent.  The evaluation shall also verify that the individual's severe mental illness has substantially affected his or her functioning in at least two of the following areas:  self maintenance, social functioning, activities of community living, work skills.  There shall be detailed documentation of how the individual's functioning in these areas has been specifically affected and documentation that the substantial functional disabilities are expected to be present for at least one year, which results in substantial limitations in major life activities.

 

e)         Documentation of severe autism shall be based on a comprehensive, documented evaluation by a licensed clinical psychologist or psychiatrist. The evaluation shall verify that a child or adult with severe autism has a lifelong developmental disability which is typically manifested before 30 months of age and is characterized by disturbances in the rate and sequences of cognitive, affective, psychomotor, language and speech development.  The diagnosis of autistic disorder shall be in keeping with DSM-III-R 299.00 criteria of autistic disorder.

 

f)         Documentation of severe and multiple impairments shall be based on a comprehensive, documented evaluation by a licensed clinical psychologist or a physician; and, depending on the individual's disability, one or more specialists.  The evaluation shall verify that the individual has a substantial disability that can be expected to continue indefinitely.  The individual meets the criteria for severe and multiple impairments based on a finding that criteria in subsections (f)(1) through (3) of this Section are met.  Each item has its own sub-criteria which also shall be met, e.g., under subsection (f)(1)(A) or (B) of this Section, shall apply.

 

1)         The evaluation determines the presence of a developmental disability based on:

 

A)        Mental retardation, which is defined as general intellectual functioning that is two or more standard deviations below the mean; or

 

B)        Cerebral palsy, epilepsy, autism or any other condition which results in impairment similar to that caused by mental retardation and which requires services similar to those required by persons with mental retardation.

 

2)         The evaluation determines multiple handicaps in physical, sensory, behavioral and/or cognitive functioning which constitute a severe or profound impairment attributable to one or more of the following:

 

A)        Physical functioning, which severely impairs or restricts the individual's motor performance that may be due to neurological, psychological or physical involvement resulting in a variety of disabling conditions, such as hemiplegia, quadriplegia, ataxia, in severe organ systems involvement such as congential defects, and other physical abnormalities resulting in the individual being non-mobile and non-ambulatory or confined to bed and receiving assistance in transferring, or requiring regular medical or nursing supervision such as gastrostomy care and feeding.

 

B)        Sensory, which involves severe restriction due to hearing and/or visual impairment limiting the individual's movement and creating dependence in completing most daily activities.

 

i)          Hearing impairment is defined, based on an evaluation by a board eligible or certified otolaryngologist or an audiologist with a Certificate of Clinical Competency, as loss of 70 dB aided or speech discrimination of less than 50% aided.

 

ii)         Visual impairment is defined, based on an evaluation by a board eligible or certified ophthamologist or a licensed optometrist, as 20/200 in the better eye or a visual field of 20 degrees or less.

 

C)        Behavioral, which involves severe or profound deficits in adaptive hehavior or severe maladaptive behavior.

 

i)          Adaptive behavior, which is at a severe or profound level of functioning for the age group in self-care skills such as feeding, dressing, grooming or bathing, in social skills such as responses or interactions with others or in communication skills such as use of words or gestures expressively or receptively.

 

ii)         Maladaptive behavior, which presents a danger to self or others, is destructive to property by deliberately breaking, destroying or defacing objects, is disruptive by fighting or prolonged arguing or crying, or has other socially offensive behaviors in sufficient frequency and/or severity to seriously limit social integration.

 

D)        Cognitive, which involves severe or profound intellectual functioning at a measured I.Q. of 40 or below.

 

3)         The evaluation determines that development is substantially less than expected for the individual's age in cognitive, affective or psychomotor behavior.

 

A)        Cognitive, which involves intellectual functioning at a measured I.Q. of 70 or below.

 

B)        Affective behavior, which involves over and under responding to stimuli in the environment and may be observed in mood, attention or awareness, or in behaviors such as euphoria, anger or sadness that seriously limit integration into society.

 

C)        Psychomotor, which includes a severe developmental delay in fine or gross motor skills so that development in self-care, social interaction, communication or physical activity shall be greatly delayed or restricted.

 

g)         Individuals or their guardians may use existing evaluations if they meet the criteria above and were completed within the following time frames:

 

1)         For assessment of severe mental illness described in subsection (d) of this Section, within one year prior to the date submitted to the Department.

 

2)         For assessment of the maladaptive behavior component of severe and multiple impairment described in subsection (f)(2)(C)(ii) of this Section, within one year prior to the date submitted to the Department.

 

3)         For all other assessments required by subsections (c)(e) and (f) of this Section, within three years prior to the date submitted to the Department.

 

h)         If existing evaluations are not available, outdated or do not meet the above criteria, individuals or their guardians shall choose the primary examiner of their choice or use Department-designated agencies or organizations to conduct the evaluations.  The completed evaluation shall be submitted with forms DMHDD-1237.1, 1237.2, 1237.3, 1237.4, 1237.5 (see Section 117.Appendix B, Illustrations A, B, C, D, E).

 

i)          The Department shall reimburse primary examiners and the other necessary examiners for the cost of the evaluation unless the individuals are eligible for partial or full payment for the evaluation by a third party payor.  In such cases, the third party payor shall reimburse for the full or partial cost, depending on the individuals' coverage, and the Department shall reimburse the balance.  The Department's reimbursement shall be tied to the usual and customary fee for such evaluations, based on the individuals' needs.

 

j)          The primary examiner shall submit the completed application and verification of disability to the Department.

 

k)         The Department shall review the completed application and verification of disability.  The Department shall notify the applicant in writing within 30 days that the application has been received and is or is not complete, and shall specify in writing what additional information is necessary.

 

l)          Should an application remain incomplete for more than 30 days after the request for additional information, the Department shall notify the applicant in writing of the incomplete status and what information is still lacking. Such notification of status shall be sent one additional time at a 30-day interval.  If, within 30 days after the final notification, the applicant has not provided the additional information, the application shall be considered inactive.

 

Section 117.145  Hearings and appeals

 

a)         If the Department denies an individual's application for participation in the programs included in this Part, the Department shall give written notice within 30 days to:

 

1)         The person who signed the application for participation in the Home-based Support Services Program; or

 

2)         The parent for the Family Assistance Program.

 

b)         The notice shall inform the individual of the right to appeal the decision and shall describe the appeal procedure.

 

c)         The person who receives the notice may appeal the Department's denial within 20 days after receipt of the Department's written notice by mailing a written appeal request of the Department (see Sections 2-13 and 3-15 of the Home-Based Support Services Law).  All appeal requests shall be sent to:

 

            Hearings and Appeals Unit

            Department of Human Services

            401 Stratton Building

            Springfield, IL  62765.

 

d)         The Department may arrange pre-hearing conferences prior to scheduling a hearing if, in the opinion of the hearing officer, such conferences could develop factors not included in the Department's master case record, could clarify the facts or issues to be determined at the hearing or could result in a resolution of the case without a formal hearing.  The individual is not required to participate in such a conference; if the individual does participate, he or she may be represented by the person of his or her choice. If the appellant and the Department agree, the appeal may be terminated at the pre-hearing conference.

 

e)         The Department shall send by certified mail a notice stating the date, time, and place of the hearing to the address given on the individual's appeal request not later than 60 days after receiving the notice of appeal, unless the appeal is terminated at the pre-hearing conference.  Hearings shall be scheduled at a time and place to be determined by the Department.  The place selected shall be an appropriate location, with a view to geographic grouping of the cases to be heard, to keep travel at a minimum for all participants.

 

f)         The individual requesting the appeal of the Department shall appear personally and may bring such witnesses as may be deemed necessary and may be represented by a person of his or her own choice.

 

g)         A hearing officer duly authorized by the Secretary shall conduct the hearing as follows:

 

1)         The hearing shall be tape or stenographically recorded.

 

2)         The hearing shall be officially opened when its purpose has been stated and governing authorities have been cited.

 

3)         The hearing officer shall present his or her credentials.

 

4)         The hearing officer shall swear in those who are to testify as witnesses, including the appellant and others appearing on his or her behalf, the Department's representative or representatives, and identify them for the record by name and title.

 

5)         The appellant shall be given preference as to the order of appearances by agreement as to the format of the hearing, as a result of a preliminary conference between both parties. If agreeable, the Department's case shall be recited first into the record for the purpose of developing a basis for the hearing. All documents, in support of such testimony, shall be numbered and offered into evidence as the Department's exhibits. Leave to substitute copies of such documents shall be sought, so the originals may be retained in the Department's master case record file.

 

6)         The common law rules of evidence shall not be enforced in the conduct of the hearing (see Section 10-40 of the Illinois Administrative Procedure Act [5 ILCS 100/10-40]). The hearing officer may ask and receive answers to such questions as are pertinent and proper for a fair determination of the case.  Exhibits may be received as part of the evidence and shall be numbered in order according to whether they are the Department's or the appellant's exhibits.

 

7)         Upon completion of the Department's case, cross examination of the Department may be held if desired, whether by the appellant or his or her attorney, if so represented.

 

8)         The appellant shall then state, either directly, or on examination by the counsel, the reason for requesting an appeal of the denial of the application, and shall submit documents to substantiate allegations made by him or her, or as a rebuttal of the Department's allegations.  These exhibits shall be numbered and identified for record purposes as applicant's exhibits.  The presiding hearing officer shall have complete authority for determining what testimony or evidence is relevant and admissible into the record, either by the Department or the appellant.

 

9)         After all direct testimony has been completed and all evidence by both the Department and the appellant is in, cross-examination may again be held, if so desired.

 

10)       When there is no further testimony, the hearing shall be adjourned.

 

h)         Within five working days after the hearing, the hearing officer shall render his or her written decision as to whether the Department presented substantial evidence that the individual did not meet the criteria for eligibility set out in Section 117.200 or Section 117.300.  Substantial evidence is such evidence as a reasonable person can accept as adequate to support a conclusion.  If the hearing officer finds there was substantial evidence to justify the Department's decision, he or she shall deny the appeal. The hearing officer's decision shall contain findings of facts and conclusions.  Copies of the decision shall be sent to the appellant and to the Department.  The appellant shall be informed that he or she may appeal the hearing officer's decision by requesting a review by the Secretary within 10 days after the receipt of the appeal.  The request must be made in writing to the Secretary.

 

i)          If an appeal is requested, the Secretary shall review the hearing officer's decision and the evidence submitted at the hearing.  Within 20 working days after receipt of the request for review, the Secretary shall issue a written decision upholding or reversing the hearing officer's decision.  The Secretary shall uphold the decision if he or she determines that the procedures set out in this Section were followed and that the decision was supported by substantial evidence.  Copies of the Secretary's decision shall be sent to the appellant and the Department.

 

j)          The Department's denial of an appeal shall constitute a final administrative decision.  Final administrative decisions shall be subject to judicial review exclusively as provided in the Administrative Review Law, as now or hereafter amended, except that any petition for judicial review of a final administrative decision by the Department under this subsection shall be filed within 30 days after receipt of notice of the Department's final administrative decision.  The term "administrative decision" has the meaning ascribed to it in Section 3-101 of the Code of Civil Procedure. (Section 2-13 of the Home-Based Support Services Law and Section 3-15 of the Family Assistance Law)

 

Section 117.200  Eligibility criteria

 

a)         The number of eligible adults chosen to participate in this program shall be contingent upon the availability of funds appropriated by the General Assembly for these purposes.

 

b)         To be eligible for the Home-Based Support Services Program an individual must:

 

1)         Reside in Illinois;

 

2)         Be between the ages of 18 and 60, inclusive;

 

3)         Reside in his or her own home or, within two months of being notified that he or she has been chosen to participate in this program, he or she shall reside full-time in his or her own home.

 

4)         Need home-based support services, but not require 24-hour-a-day supervision;

 

5)         Be eligible and must have applied for federal Supplemental Security Income (SSI) (42 U.S.C.A. 1381 (1996)) or federal Social Security Disability Income (SSDI) (42 U.S.C.A. 401 (1996)) benefits;

 

6)         Be diagnosed as having one of the following conditions:

 

A)        Severe autism;

 

B)        Severe mental illness;

 

C)        Severe or profound mental retardation; or

 

D)        Severe and multiple impairments.

 

7)         Apply annually.

 

8)         Not receive CILA services in conjunction with this Section.  (Community Integrated Living Arrangements Licensure and Certification Act [210 ILCS 135].

 

Section 117.205  Notice of eligibility and service authorization

 

a)         The Department shall notify individuals found eligible, in writing, within 30 days after final approval of their applications.  This notification shall include instructions for accessing services and the names of Department-designated agencies that can assist the individual in developing a service/treatment plan.

 

b)         The service facilitator shall send a copy of the service/treatment plan, signed by the individual or his or her guardian, to the Department within 60 days from the date of the Department's final approval of the application. Payment for services shall be based on the plan and services delivered shall be consistent with the plan.

 

c)         If an individual chosen to participate in this program is receiving Department-funded purchase of care or grant-in-aid services, reimbursement for his or her support under this program shall be reduced based on the Department's costs of the individual's purchase of care or grant-in-aid services.  The individual can choose, however, to design his or her individualized plan to include newly-arranged services that may better meet the individual's needs and for which there is no offset.

 

Section 117.210  Notice of ineligibility and right to appeal

 

a)         If, based on the evaluations as described in Section 117.140, the individual is found ineligible, the Department shall notify him or her or the guardian in writing within 30 days.

 

b)         Appeal of a service denial may be made as provided for in Section 117.145.

 

Section 117.215  Services and funding provisions

 

a)         The Department shall purchase services from service agencies, organizations or individuals based on the service/treatment plan.  Such services may include, but are not limited to:

 

1)         Home health services;

 

2)         Service facilitation;

 

3)         Crisis management;

 

4)         Training and assistance in self-care;

 

5)         Personal care services;

 

6)         Habilitation and rehabilitation services;

 

7)         Employment-related services;

 

8)         Supported employment;

 

9)         Respite care for the caregiver; and

 

10)       Other skills training that enables an individual to become self-supporting.

 

b)         Home-based support services may not be used to:

 

1)         Replace services for which the individual is otherwise eligible through federal, state or local public agencies such as special education programs, as described in 42 CFR 430, Subpart A (1996).

 

2)         Deny, reduce or terminate services to individuals participating in this program.

 

c)         The amount of home-based support services shall be determined by the individual's service/treatment plan but shall not exceed the following:

 

1)         For adults who are not in a special education program, the cost of services shall be up to 300 percent of the monthly federal SSI payment for a person living along (Section 2-6 of the Home-Based Support Services Law).

 

2)         For adults who are in a special education program, the cost of services shall be up to 200 percent of the monthly federal SSI payment for a person living alone (Section 2-6 of the Home-Based Support Services Law).

 

Section 117.220  Service facilitation services

 

a)         The Department shall notify individuals who are chosen to participate in the program in writing of the availability of an array of community services which Department-designated agencies can provide, including service facilitation.

 

b)         Periodically, as desired by the individual but no less than annually, the service facilitator shall review with the individual the adequacy of the plan and make any modifications desired by the individual.

 

Section 117.225  Service/treatment plan

 

a)         The service/treatment plan shall be developed by the individual, his or her guardian, and other persons the individual asks to participate as well as a service facilitator.

 

b)         The plan shall serve as the basis on which services may be billed by an agency, organization or individual  and reimbursed by the Department.

 

Section 117.230  Selection of services

 

Individuals whose eligibility has been verified and who have a completed service/treatment plan shall receive services on a monthly basis not to exceed the funding level set by the plan.

 

Section 117.235  Service monitoring

 

Annually, the Department through on-site field review shall monitor a sample of the service/treatment plans of participating individuals to assure services are meeting the plans' stated goals, the needs of the individuals being served, and to ensure that the individuals are satisfied with the services which they are receiving.

 

Section 117.240  Service termination

 

a)         The funding for services will cease if any of the following occur:

 

1)         The adult no longer meets the eligibility criteria;

 

2)         The adult dies;

 

3)         The adult reaches the age of 61 years; or

 

4)         The adult or guardian submits false information during the application process.

 

b)         Changes in eligibility shall be reported by the individual or his or her guardian to the Department in writing within 30 days after such changes occur.

 

Section 117.300  Eligibility criteria

 

a)         The number of eligible families chosen to participate in the Family Assistance Program shall be contingent upon the availability of funds appropriated by the General Assembly for these purposes.

 

b)         To be eligible, a family must meet all of the following criteria:

 

1)         Have a child 17 years old or younger who has a diagnosis of one of the conditions described in Section 117.200(b)(6) and who lives in the home.  The eligible child may be living in an out-of-home placement at the time of application but must live with the parent within 60 days after the date of being notified of acceptance.

 

2)         Reside in Illinois.

 

3)         Have a maximum household federal taxable income of less than $65,000 annually (natural or adoptive family) as verified by the family's federal income tax return.  Income eligibility shall be based on the year immediately preceding the date of application, unless the family can verify that its federal taxable income shall be less in the year the application is made.  Families who can verify that they did not file an income tax return because of limited income shall be considered eligible.  Such families shall be required to verify household income by listing all of their income from all sources from the previous year.  The family income limit shall not apply to children in foster care.  In such cases, the foster child's income shall be the determinant.

 

4)         Apply annually.

 

(Source:  Amended at 32 Ill. Reg. 9976, effective June 25, 2008)

 

Section 117.305  Eligibility determination process

 

The eligibility determination process for the Family Assistance Program shall be conducted as follows:

 

a)         Documentation of severe or profound mental retardation shall be in accordance with Section 117.140(c).

 

b)         Documentation of a severe emotional disturbance shall be based on a comprehensive, documented evaluation by a licensed clinical psychologist or psychiatrist who shall verify that the child has a primary diagnosis which meets the DSM-III-R criteria of a mental disorder with onset in childhood or adolescence (excluding V-codes, adjustment disorders, mental retardation when no other mental disorder is present, or other forms of dementia based on organic, physical or alcohol/substance abuse disorders).  A child who suffers from this severe disability requires sustained treatment intervention for a year or more and generally requires attention from two or more agencies.  The child must meet DSM-III-R Axis V criteria of severe functional impairment (a score of 40 or below on the Global Assessment of Functioning Scale (GAF Scale) contained in the DSM-III-R) and must be experiencing significant limitations of major life activities in his or her capacity for living in a family or family equivalent and in two or more of the following areas (not to include impairment in functioning due to physical or environment limitation):

 

1)         Self-care at an appropriate developmental level;

 

2)         Perceptive and expressive language;

 

3)         Learning; or

 

4)         Social interaction and self-direction, including behavioral controls, decision-making, judgment and value systems at an appropriate developmental level.

 

c)         Documentation of severe autism shall be in accordance with Section 117.140(e).

 

d)         Documentation of severe and multiple impairments shall be in accordance with Section 117.140(f).

 

e)         Families shall submit, with documentation of the child's severe disability, verification of income in accordance with Section 117.300(b)(3).

 

Section 117.310  Notice of eligibility or ineligibility

 

The Department shall notify families in writing within 30 days after its final approval or disapproval of the application.

 

Section 117.315  Right to appeal

 

Appeal of a service denial may be made as set forth in Section 117.145.

 

Section 117.320  Services and funding provisions

 

a)         The family shall use the monthly stipened to assist in meeting the expenses associated with the child's presence in the family home.  The child's parent shall be responsible for determining the stipend's use.  Examples of such uses of the stipend include:

 

1)         Respite care;

 

2)         Purchase of special equipment and supplies needed by the child;

 

3)         Individual or family counseling;

 

4)         Training for a parent or sibling;

 

5)         Home remodeling to meet the needs of the child; or

 

6)         A special car or a lift for a van to transport the eligible child.

 

b)         Annually, the parent shall submit to the Department a signed, written statement verifying that the stipend was used to meet the special needs of the family.

 

c)         The stipend shall be considered a benefit to the child and shall be paid monthly to the eligible child's parent.  The amount shall be equal to the amount of the monthly SSI payment for an individual residing alone.

 

d)         If the child is living outside the home, the family may apply for a single, one-time advance payment not to exceed twice the monthly stipend to prepare family members and/or the family home to meet the special needs of the eligible child.  The monthly payment as described in subsection (c) of this Section shall begin during the month of the child's return home.

 

Section 117.325  Service facilitation services

 

The Department shall inform the family of eligible children in writing of the availability of service facilitation services.  When serving families, the service facilitator shall provide information to the family concerning local support services, including but not limited to in-home services, crisis intervention, and respite care and shall advocate for the family in accessing desired services.  The service facilitator's role is to assist the family to make its own decisions and choices by providing the family with information needed to better access the service system; to make the family aware of generic services that are available in the community; to assist in advocating for the family's expressed needs and desires; and to work with the family to creatively make suggestions regarding some potential uses of the family assistance dollars.

 

Section 117.330  Stipend termination

 

a)         Payment of the stipend shall cease when any of the following occur:

 

1)         The family no longer meets the eligibility criteria;

 

2)         The eligible child attains the age of 18;

 

3)         The eligible child moves from the family home;

 

4)         The parent no longer has custody of the child;

 

5)         The family fails to make a report on any of the eligibility standards described in subsections (a)(1) through (4) of this Section as required by Section 117.320;

 

6)         The parent does not submit the annual verification statement on the use of the funds to the Department as required by Section 117.320(b);

 

7)         The parent submits false information to the Department in an application or a verification statement regarding the stipend's use;

 

8)         The eligible child is abused or neglected as reported under the provisions of the Abuse and Neglected Child Reporting Act [325 ILCS 5] and as confirmed by the Department of Children and Family Services; or

 

9)         The family uses the monthly stipend for alcohol, illegal drugs, gambling or any illegal activities.

 

b)         The parent shall report changes in eligibility in writing to the Department within 30 days after such changes occur.

 

c)         If the family moves, the parent shall report the change of address in writing to the Department within 14 days.

 

Section 117.335  Right to investigate suspected fraud

 

The Department reserves the right to investigate suspected fraud of the Family Assistance Program and to take necessary action if such fraud is found.

 

Section 117.340  Denial of other services

 

Families participating in this program shall not be denied generic or specialized services available to all families with mentally disabled children because they are receiving a monthly stipend.  Department-funded agencies shall not terminate services currently being offered to the eligible child due to the family's participation in this program nor shall the agencies introduce a service fee that was not in place prior to the family's participation in this program.

 

Section 117.345  Maximizing the use of other agency services

 

A family shall maximize the use of services and entitlements as provided by other governmental agencies such as provider agencies, SSI, SSDI, services of the Department, and special education services.

 

Section 117.350  Out-of-home placement

 

When the Department receives an application for out-of-home placements for children with severe mental disabilities, the Department shall make the parents aware of the availability of the Family Assistance Program.  However, no entitlement to this program exists for such children.

Section 117.APPENDIX A   Preliminary Application forms

 

Section 117.ILLUSTRATION A   DMHDD-1235, Home-Based Support Services Program Application

 

Illinois Department of Human Services

THE PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION

A new program for adults with a severe developmental disability or a severe mental illness.  For more information call the Department's toll free number 1-800-843-6154.

Please read the brochure before completing items 1-10 below, print or type clearly and sign the application:

1.

Applicant's name:

2.

Sex:

Male

Female

3.

Applicant's race

White

Black

Hispanic

Other

4.

Applicant is believed to have:

severe autism;

severe mental illness;

severe or profound mental retardation;

severe and multiple impairments.

5.

Applicant's birthdate:

/

/

6.

Applicant's social security number:

7.

Applicant's address:

Street

City

State

Zip

County

8.

Applicant's telephone number:

Area code

Number

9.

a.

The applicant lives in his/her own home/apartment now:

Yes

No

b.

The applicant lives outside his/her home now but is a planning to move to his/her own home/apartment if chosen to participate in this program:

Yes

No

10.

Applicant is enrolled in a special education program

Yes

No

I declare that the information above is true and I understand that if I am chosen this information will be confirmed by the Illinois Department of Human Services through an assessment to assure my eligibility to participate in the Home-Based Support Services Program.

Applicant's or guardian signature

Date

Guardian's name

Guardian's telephone number:

Guardian's address:

 

Section 117.APPENDIX A   Preliminary Application forms

 

Section 117.ILLUSTRATION B   DMHDD – 1236, Family Assistance Program Application

 

Illinois Department of Human Services

THE PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION

A new program for adults with a severe developmental disability or a severe mental illness.  For more information call the Department's toll free number 1-800-843-6154.

Please read the brochure before completing items 1-10 below, print or type clearly and sign the application:

1.

Child's name:

2.

Sex:

Male

Female

3.

Child's race

White

Black

Hispanic

Other

4.

I believe my child has:

severe autism;

severe emotional disturbance;

severe or profound mental retardation;

severe and multiple impairments.

5.

Child's birthdate:

/

/

6.

Child's social security number (if available):

7.

Parent's/guardian's Name:

Street address:

City

State

Zip

County

8.

Parent's/guardian's telephone number:

9.

Family taxable income:

under $50,000

over $50,000

10.

a.

My child lives in the family home now:

Yes

No

b.

My child lives outside the family home now, but if I am chosen to participate in this program I plan to bring my child back into the family home:

Yes

No

11.

Is this a foster child:

Yes

No

I declare that the information above is true and I understand that if I am chosen this information will be confirmed by the Illinois Department of Human Services through an assessment to assure my eligibility to participate in the Home-Based Support Services Program.

Parent/guardian signature

Date

 

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