Ill. Admin. Code tit. 59, § 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:

Applicant's name:

Sex:

Male

Female

Applicant's race

White

Black

Hispanic

Other

Applicant is believed to have:

severe autism;

severe mental illness;

severe or profound mental retardation;

severe and multiple impairments.

Applicant's birthdate:

Applicant's social security number:

Applicant's address:

Street

City

State

Zip

County

Applicant's telephone number:

Area code

Number

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

Yes

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

10.

Applicant is enrolled in a special education program

Yes

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:

Child's name:

Sex:

Male

Female

Child's race

White

Black

Hispanic

Other

I believe my child has:

severe autism;

severe emotional disturbance;

severe or profound mental retardation;

severe and multiple impairments.

Child's birthdate:

Child's social security number (if available):

Parent's/guardian's Name:

Street address:

City

State

Zip

County

Parent's/guardian's telephone number:

Family taxable income:

under $50,000

over $50,000

10.

My child lives in the family home now:

Yes

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

11.

Is this a foster child:

Yes

Parent/guardian signature

Date