Instructions for Completing Referral Form

Instructions for Completing the Referral for Monitoring and Technical Assistance Form

  1. It is not always necessary to enter names of individuals on the form or to specify site information. If there are issues that are agency-wide and do not specifically apply to any individual or site, the sections for individuals' names and site addresses may be left blank.
  2. If more than 4 people are concerned at the site, include the remaining individuals' names in the description or attach a separate page.
  3. If concerns are site-specific, do not include more than one site on a form.
  4. You may install this form in a word processor and expand its length if necessary.
  5. Send a copy to the primary direct service provider for each individual listed on the form and to any providers listed on the form.
  6. Send the form to:

    Illinois Department of Human Services
    Division of Developmental Disabilities 
    600 East Ash, Building 400, Mail Stop 3
    Springfield, IL 62703

    Fax: (217) 558-2799

ISSAs may identify additional situations for which referrals are also appropriate. The following guidelines indicate some situations for which referral to the Division is indicated:

  • Finding of unauthorized use of restraint or seclusion or injury to individual resulting from the use of restraint regardless of authorization.
  • Significant serious concern for health and safety of an individual or individuals.
  • Individual appears to be at risk of losing one or more services.

    Note: Do not use this referral process for appeals of reduction or termination of services. Appeals should follow the process described in Rule 120. Referrals should be made under this process before the provider reaches the point of termination.

  • Identified service problems have remained unaddressed after Step 3 of the Problem and Conflict Resolution protocol.
  • ISSA has identified serious deficits in service provision that appear to be systemic in nature, affecting more than one individual within a single agency.