Get Illinois Petitioner Treatment Verification

The Illinois Petitioner Treatment Verification form is essential for individuals undergoing assessment for alcohol or drug-related treatment. This guide will help you navigate the online completion of the form, providing clear instructions for each section.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the Illinois Petitioner Treatment Verification form and open it in your preferred online editor.
2. Provide your personal information in the petitioner information section, including your name, Illinois driver’s license number, address, sex, date of birth, home telephone number, and work telephone number.
3. Fill in the referral source to indicate who referred you for treatment.
4. Enter the admission date and discharge date for your primary treatment, avoiding follow-up or aftercare dates.
5. Detail your admission and discharge diagnoses or provide the treatment needs assessment date and diagnosis.
6. Indicate the treatment modality by checking the relevant box and stating the number of hours completed for outpatient and intensive outpatient counseling or the number of days spent in inpatient treatment.
7. Provide your prognosis after completing treatment and the treatment needs assessment, explaining your overall view of the effectiveness of the treatment.
8. Offer a clinical impression detailing the petitioner’s progress and potential for maintaining recovery.
9. List recommendations for aftercare or follow-up services and their current status.
10. Justify any changes in treatment hours or modality, treatment waiver, or further treatment recommendations from the treatment needs assessment.
11. Fill in the provider’s details, including name, signature, date, title, telephone number, program name, accreditation/license number, and address.
12. Once you have filled out all fields, ensure all information is accurate, then save changes. You can download, print, or share the form as necessary.

Complete the Illinois Petitioner Treatment Verification form online to ensure your treatment documentation is submitted promptly.