Get Illinois Somb Provider List

The Illinois SOMB Provider List is a crucial document for professionals seeking placement as qualified evaluators and treatment providers in the field of sexual offender management. This guide provides comprehensive, step-by-step instructions on how to effectively fill out the application online, ensuring all necessary information is accurately provided.

Follow the steps to complete your application for the Illinois SOMB Provider List online.

1. Press the ‘Get Form’ button to access the application for placement on the Illinois SOMB Approved Provider List and open it in your document editor.
2. Fill in the provider information section. Provide your full name, agency name, agency address, telephone number, fax number, and email address.
3. Indicate the counties in which you provide services by listing them clearly.
4. List all currently held licenses and/or certifications relevant to your qualifications.
5. Specify any languages you speak or sign fluently, other than English, that you can use to provide your services.
6. Select the services you currently provide by checking the applicable boxes for sex offender evaluation, sex offender treatment, adult offenders, and juvenile offenders.
7. If applying for the treatment provider list, initial each item in Section II to attest that you meet all qualifications.
8. If applying for the evaluation provider list, initial each item in Section III to confirm that you meet the necessary requirements.
9. In the applicant attestation section, initial each statement in Section IV to acknowledge your understanding and agreement with the conditions outlined.
10. Affix your signature and date at the end of the application to affirm that all the information is accurate to the best of your knowledge.
11. Once completed, save your changes. You can then download, print, or share the form as needed.

Complete the Illinois SOMB Provider List application online to become a recognized provider.