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:

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