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Office of Mental Health

New York State Office of Mental Health
Home and Community-Based Services
Application for Participation and Freedom of Choice

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Name of Child:

Current Address





Social Security #:

Date of Birth

Name of HCBS Program for Which Applying

I am requesting participation in the HCBS Waiver for Children and Adolescents with Serious Emotional Disturbance. I understand that approval will be based on my choice of home and community based services in preference to care in psychiatric inpatient services for children under 21 and on evidence of my child's:

I/we have been informed that may be eligible for care and treatment in a (name of child/adolescent) hospital or through Home and Community Based Services (HCBS). I/we have also been informed that, if the child/adolescent is eligible, he/she has a choice between hospital care and HCBS and also a choice of feasible alternatives available under HCBS.

Child/Adolescent's Signature (As appropriate)

Name of Parent/Guardian

Signature of Parent/Guardian

Signature of Witness