Ill. Admin. Code tit. 59, pt. 117, subpt. C, app A, ILLUSTRATION A

Current through Register Vol. 49, No. 2, January 10, 2025

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:MaleFemale

3. Applicant's raceWhiteBlackHispanicOther

4. Applicant is believed to have:severe autism;severe mental illness;

5. Applicant's birthdate: ___/ ___ /___

6. Applicant's social security number: ______________________________________

7. Applicant's address: _________________________________________________

Street

_________________________________________________________________

CityStateZipCounty

8. Applicant's telephone number: ____________________________________________

Area codeNumber

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

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:

YesNo

10. Applicant is enrolled in a special education programYesNo

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 signatureDate

- Guardian's name ________________________________________________________

- Guardian's telephone number: ______________________________________________

- Guardian's address: _____________________________________________________

Ill. Admin. Code tit. 59, pt. 117, subpt. C, app A, ILLUSTRATION A