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 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