Voucher Program Eligibility Verification Form printable pdf download

The Recreation Council of Greater St. Louis

VOUCHER PROGRAM ELIGIBILITY VERIFICATION FORM

This mandatory form may be completed by a St. Louis Regional Center Support Coordinator or a physician. St. Louis

Regional Center Support Coordinator please include copy of CIMOR page with client name and diagnosis.

Customer’s Name: _________________________________

Customer’s Date of Birth:______________

1) Does this individual live in St. Louis County? ___ YES ___ NO

2) Has the St Louis Regional Center determined this customer has a developmental disability? ___Yes ___No

Please check the Customer’s Diagnosis:

__Autism

__Cerebral Palsy

__Intellectual Disability

__Epilepsy

__Head Injury

__Other** (Must check one):

__ADHD

__Developmental Delays

__Behavior Disorder

__Spina Bifida

__Learning Disability

__Other_______________

**If you checked Other** you must also check the substantial

functional limitations in 2 or more of the following areas:

__Capacity for Independent Living

__Learning

__Self Care

__Mobility

__Receptive & Expressive Language

__Self Direction or Economic Self Sufficiency

___Prior to age 19

___Prior to age 22

When did this customer’s disability manifest itself?

3) It is my professional opinion that the above named customer requires the following supervision/care (due to

personal care assistance needs and/or due to positive behavior support needs) while in programming: .

___ 1 staff to 1 customer ___ 2 staff to 3 customers

___ 1 staff to 4 customers

___ 1 staff to 8 customers ___ Other:

4) Current Residence Type:

_Lives with Family/Guardian

_Individualized Supported Living

_Lives Independently

_Homeless/Emergency Shelter _Specialized Facility

_Nursing Home _Group Home

_Habilitation Center

_State Group Home

_Foster Home**: If foster home check: _Temporary

_Long-Term (over 2 years)

**Was foster home placement made by St, Louis County Courts? __Yes __ No, explain_______________

5) Is the above date of birth correct? ___Yes

___ No

If no, date of birth: ________________

6) Customer’s Social Security Number ________ - _________ - _______

7) Customer’s gender: _____Male _______Female

8.) DMH Case Number _______________________

9) Are you aware of other funding that might assist this customer in obtaining funding for recreation programming?

____ Yes ____No

If yes, please list funding: ____________________________________________________

To the best of my knowledge the information I am disclosing is true.

Signature: ___________________________________________

Date: ________________________

Print Name: __________________________________________

Agency:_______________________________

Title:________________________________________________

Phone Number:_________________________

Address:__________________________________________________________________________________________

Street

City

State

Zip Code

Thank you in advance for your time in completing this form, your assistance is greatly appreciated! If you have any

questions, please feel free to contact Margaret Tucker, the County Coordinator for the Recreation Council, at

(314) 726-6044. This form may be faxed back by the verifier to The Recreation Council at (314) 726-3454 or mailed to:

The Recreation Council ~200 South Hanley, Suite 100~ St. Louis, Missouri 63105

Voucher Program Eligibility Verification Form

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