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).
 |
TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.125 INDIVIDUALS' RECORDS AND INFORMED CONSENT
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.130 OUTREACH PLAN
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.135 PRELIMINARY APPLICATION PROCESS
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.140 APPLICATION AND ELIGIBILITY DETERMINATION PROCESS
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.145 HEARINGS AND APPEALS
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)
SUBPART B: HOME-BASED SUPPORT SERVICES PROGRAM
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.200 ELIGIBILITY CRITERIA
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].
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.205 NOTICE OF ELIGIBILITY AND SERVICE AUTHORIZATION
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.210 NOTICE OF INELIGIBILITY AND RIGHT TO APPEAL
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.215 SERVICES AND FUNDING PROVISIONS
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).
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.220 SERVICE FACILITATION SERVICES
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.225 SERVICE/TREATMENT PLAN
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.230 SELECTION OF SERVICES
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.235 SERVICE MONITORING
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.240 SERVICE TERMINATION
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.
SUBPART C: FAMILY ASSISTANCE PROGRAM
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.300 ELIGIBILITY CRITERIA
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)
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.305 ELIGIBILITY DETERMINATION PROCESS
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).
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.310 NOTICE OF ELIGIBILITY OR INELIGIBILITY
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.315 RIGHT TO APPEAL
Section 117.315 Right to
appeal
Appeal of a service denial may
be made as set forth in Section 117.145.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.320 SERVICES AND FUNDING PROVISIONS
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.325 SERVICE FACILITATION SERVICES
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.330 STIPEND TERMINATION
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.335 RIGHT TO INVESTIGATE SUSPECTED FRAUD
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.340 DENIAL OF OTHER SERVICES
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.345 MAXIMIZING THE USE OF OTHER AGENCY SERVICES
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.
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.350 OUT-OF-HOME PLACEMENT
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
 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.APPENDIX A PRELIMINARY APPLICATION FORMS
Section 117.APPENDIX A
Preliminary Application forms
Section 117.ILLUSTRATION A
DMHDD-1235, Home-Based Support Services Program Application
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Illinois
Department of Human Services
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THE
PRELIMINARY FAMILY ASSISTANCE PROGRAM APPLICATION
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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.
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Please read the brochure
before completing items 1-10 below, print or type clearly and sign the
application:
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1.
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Applicant's name:
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2.
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Sex:
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Male
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Female
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3.
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Applicant's race
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White
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Black
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Hispanic
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Other
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4.
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Applicant is believed to have:
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severe autism;
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severe mental illness;
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severe or
profound mental retardation;
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severe and multiple
impairments.
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5.
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Applicant's birthdate:
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/
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/
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6.
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Applicant's
social security number:
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7.
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Applicant's
address:
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Street
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City
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State
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Zip
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County
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8.
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Applicant's
telephone number:
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Area code
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Number
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9.
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a.
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The applicant lives in his/her
own home/apartment now:
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Yes
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No
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b.
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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:
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Yes
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No
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10.
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Applicant is enrolled in a
special education program
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Yes
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No
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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.
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Applicant's or guardian
signature
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Date
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Guardian's name
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Guardian's telephone number:
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Guardian's address:
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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:
|
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|
|
2.
|
Sex:
|
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Male
|
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Female
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3.
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Child's race
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White
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Black
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Hispanic
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Other
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4.
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I believe my child has:
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severe autism;
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severe emotional disturbance;
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severe or
profound mental retardation;
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severe and multiple
impairments.
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5.
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Child's birthdate:
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/
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/
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6.
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Child's
social security number (if available):
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7.
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Parent's/guardian's
Name:
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Street
address:
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City
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State
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Zip
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County
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8.
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Parent's/guardian's
telephone number:
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9.
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Family taxable income:
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under
$50,000
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over
$50,000
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10.
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a.
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My child lives in the family
home now:
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Yes
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No
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b.
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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:
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Yes
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No
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11.
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Is this a foster child:
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Yes
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No
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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.
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Parent/guardian
signature
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Date
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 | TITLE 59: MENTAL HEALTH
CHAPTER I: DEPARTMENT OF HUMAN SERVICES
PART 117
FAMILY ASSISTANCE AND HOME-BASED
SUPPORT PROGRAMS FOR PERSONS WITH MENTAL DISABILITIES
SECTION 117.APPENDIX B ELIGIBILITY DETERMINATION FORMS
Section 117.APPENDIX B
Eligibility determination forms
Section 117.ILLUSTRATION A
DMHDD-1237.2, Eligibility Determination – Primary Examiners – Adults with a
Severe Mental Illness
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Illinois
Department of Human Services
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ELIGIBLITY
DETERMINATION – PRIMARY EXAMINERS
–
ADULTS WITH A SEVERE MENTAL ILLNESS
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Name of applicant:
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Date of examination:
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I verify that I
am a
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board eligible/certified
psychiatrist
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licensed clinical psychologist
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and that the above–named
individual was evaluated personally by me.
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I verify that I have found the
person to meet the eligibility criteria for determination as an Adult with a
Severe Mental Illness
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I verify that I have found the
person does not meet the eligibility criteria for determination as an Adult
with a Severe Mental Illness.
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I have attached my evaluation
and copies of any other evaluations used by me in making this determination.
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Name (type or print)
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Signature
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Address
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License no.
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Return in self-addressed,
stamped envelope or send to:
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Department of Human Services
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Home-Based Support Services
Program
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Room 405 Stratton Building
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Springfield IL 62765
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Section 117.APPENDIX B
Eligibility determination forms
Section 117.ILLUSTRATION B
DMHDD-1237.2, Eligibility Determination – Primary Examiners – Children with
Severe Emotional Disturbance
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Illinois
Department of Human Services
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ELIGIBLITY
DETERMINATION – PRIMARY EXAMINERS
–
CHILDREN WITH A SEVERE EMOTIONAL DISTURBANCE
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Name of applicant:
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Date of examination:
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I verify that I am a
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board eligible/certified
psychiatrist
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licensed clinical psychologist
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and that the above–named
individual was evaluated personally by me.
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I verify that I have found the
person to meet the eligibility criteria for determination as a Child with a
Severe Emotional Disturbance.
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I verify that I have found the
person does not meet the eligibility criteria for determination as a Child
with a Severe Emotional Disturbance.
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I have attached my evaluation
and copies of any other evaluations used by me in making this determination.
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Name (type or print)
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Signature
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Address
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License no.
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Return in self-addressed,
stamped envelope or send to:
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Department of Human Services
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Home-Based Support Services
Program
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Room 405 Stratton Building
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Springfield IL 62765
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Section 117.APPENDIX B
Eligibility determination forms
Section 117.ILLUSTRATION C
DMHDD-1237.3, Eligibility Determination – Primary Examiners – Children and
Adults with Severe Autism
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Illinois
Department of Human Services
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ELIGIBLITY
DETERMINATION – PRIMARY EXAMINERS
–
CHILDREN AND ADULTS WITH A SEVERE AUTISM
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Name of applicant:
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Date of examination:
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I verify that I am a
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board eligible/certified
psychiatrist
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licensed clinical psychologist
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and that the above–named
individual was evaluated personally by me.
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I verify that I have found the
person to meet the eligibility criteria for determination as Children and
Adults with a Severe Autism.
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I verify that I have found the
person does not meet the eligibility criteria for determination as Children
and Adults with a Severe Autism.
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I have attached my evaluation
and copies of any other evaluations used by me in making this determination.
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Name (type or print)
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Signature
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Address
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License no.
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Return in self-addressed,
stamped envelope or send to:
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Department of Human Services
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Home-Based Support Services
Program
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Room 405 Stratton Building
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Springfield IL 62765
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Section 117.ILLUSTRATION D
DMHDD-1237.4, Eligibility Determination – Primary Examiners – Children and
Adults with Severe or Profound Mental Retardation
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Illinois
Department of Human Services
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ELIGIBLITY
DETERMINATION – PRIMARY EXAMINERS – CHILDREN AND ADULTS WITH A SEVERE OR
PROFOUND MENTAL RETARDATION
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Name of applicant:
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Date of examination:
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I verify that I am a
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licensed clinical psychologist
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certified school psychologist
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and that the above–named
individual was evaluated personally by me.
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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.
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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.
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I have attached my evaluation
and copies of any other evaluations used by me in making this determination.
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Name (type or print)
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Signature
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Address
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License no.
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Return in self-addressed,
stamped envelope or send to:
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Department of Human Services
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Home-Based Support Services
Program
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Room 405 Stratton Building
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Springfield IL 62765
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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
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Illinois
Department of Human Services
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ELIGIBLITY
DETERMINATION – PRIMARY EXAMINERS
–
CHILDREN AND ADULTS WITH SEVERE AND MULTIPLE IMPAIRMENTS
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Name of applicant:
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Date of examination:
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I verify that I am a
|
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board eligible/certified
psychiatrist
|
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|
|
|
licensed clinical psychologist
|
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|
|
|
licensed physician
|
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and that the above–named
individual was evaluated personally by me.
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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.
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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.
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I have attached my evaluation
and copies of any other evaluations used by me in making this determination.
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Name (type or print)
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Signature
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Address
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License no.
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Return in self-addressed,
stamped envelope or send to:
|
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|
|
|
Department of Human Services
|
|
|
Home-Based Support Services
Program
|
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|
Room 405 Stratton Building
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Springfield IL 62765
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