Skip to Main Content
NY.gov Portal State Agency Listing Search all of NY.gov
Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

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

View Adobe Acrobat Version | Download Adobe Acrobat Reader

Name of Child:

Current Address

Street

City

Zip

County

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

Date

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.