- Completed and signed application. The third and fourth pages are only used if you are applying for funding for more than one individual in the household.
- The last two months of bank statements you and your spouse/significant other received (for adults only). If you receive SSI/SSDI on a Direct Express Card, you can obtain your recent account activity at http://www.usdirectexpress.com or by calling 1-888-741-1115.
- Copies of paystubs or proof of income for the last two months for you and all members of your household.
- For adults (18 and over): includes the individual, the individual’s spouse or domestic partner, and any children, step-children, or wards under the age of 18 who reside with the individual.
- For children (under 18): includes the individual, the individual’s parents (or parent and domestic partner), stepparents or guardians, and any children, stepchildren, or wards under the age of 18 of the individual’s parents (or parent and domestic partner), stepparents, or guardians who reside with the individual.
- A copy of your visa or green card if you are not a citizen of the US.
- A signed Release of Information for each agency for which you would like funding and any other agency or person you would like us to be able to get information from or give information to.
- Please fill in your name and demographic information as well as the provider/individual’s name and address.
- You must use a separate release for each individual/provider. If you need additional releases, please make copies of the release or request releases from one of the county offices listed below.
- Make sure you sign the release above the first dark line. If you would like substance abuse or information regarding AIDS released, please check the applicable box and sign this section also.
- Please do not sign a blank Release of Information since it cannot be used.
- A signed Copy of the “Authorization for the Use or Disclosure of Confidential Information” (ISAC Multi-Party ROI) form so the region can obtain or release information with other regions and counties if needed to determine eligibility or approve services.
For Adults: An approved application is sufficient for outpatient mental health services. Other services require proof of a qualifying diagnosis and an assessment of needs (see MHDS of ECR Management Plan). You will be asked to provide this information or sign a release for the provider who can supply the information.
For Children: An approved application is sufficient for an evaluation. Additional outpatient mental health services require proof of a qualifying diagnosis of serious emotional disturbance.
- Please remember to write down the services you are requesting and the provider you wish to use. If you do not know who you want for an outpatient mental health provider, call the intake office at 319-892-5671 and they will provide options.
- Please do not leave questions blank. If they are not applicable (N/A) or $0, please indicate this.
- List all income, before taxes, that was received by you or your spouse/significant other. This would include child support, alimony, disability benefits, unemployment insurance or other benefits. Do not include employment income for minors.
- List child support that you or your significant other pay and provide documentation of the payment for the past two months.
- Be sure to list the name of any medical insurance company and policy number that you may have, including Medicare and Medicaid/Title 19/MCO.
email@example.com (please send via secure e-mail)
MHDS of the ECR
1240 26th Ave Court SW
Cedar Rapids, IA 52404