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Menu
Home
Ceda
LIHEAP
Share The Warmth
Water Assistance
Furnace Assistance
Weatherization
Behavioral Health
Behavioral Health Programs
Public Benefits
Education
Employment
Adult
upcoming Event
Registration form
About Us
Board of Directors
FAQ’s
Contact Us
BEHAVIORAL HEALTH INTAKE REQUESTS
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adult outpatient
child & adolescent
Adult Outpatient
Name
Email
Birthdate
Zip Code
Had Insurance?
Yes
No
Insurance Type
Medicaid
Blue Cross Blue Shield of Illinois (MCO – Managed Care Organization)
CountyCare Health Plan (MCO – Managed Care Organization)
Harmony Health Plan (MCO – Managed Care Organization)
Illinicare Health (MCO – Managed Care Organization)
Meridian Health Plan (MCO – Managed Care Organization)
Molina Healthcare (MCO – Managed Care Organization)
NextLevel Health Partners (MCO – Managed Care Organization)
Private Insurance (HMO/PPO)
Other*
Medicaid/Insurance ID Number
Best Call Back Number *
Best Call Back Time
Preferred Language
Select Language
Afrikaans
Albanian
Arabic
Armenian
Azerbaijani
Basque
Belarusian
Bengali
Bosnian
Bulgarian
Burmese
Catalan
Cebuano
Chichewa
Chinese (Simplified)
Chinese (Traditional)
Corsican
Croatian
Czech
Danish
Dutch
Esperanto
Estonian
Filipino
Finnish
French
Frisian
Galician
Georgian
German
Greek
Gujarati
Haitian Creole
Hausa
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Icelandic
Igbo
Indonesian
Irish Gaelic
Italian
Japanese
Javanese
Kannada
Kazakh
Khmer
Korean
Kurdish (Kurmanji)
Kyrgyz
Lao
Latin
Latvian
Lithuanian
Luxembourgish
Macedonian
Malagasy
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Nepali
Norwegian
Pashto
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Scots Gaelic
Serbian
Sesotho
Shona
Sindhi
Sinhala
Slovak
Slovenian
Somali
Spanish
Sundanese
Swahili
Swedish
Tajik
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Yiddish
Yoruba
Zulu
Submit
Child & Adolescent (C&A)
Name
Child's Name
School Name
Email
Child's Birthdate
Zip Code
Had Insurance?
Yes
No
Insurance Type
Medicaid
Blue Cross Blue Shield of Illinois (MCO – Managed Care Organization)
CountyCare Health Plan (MCO – Managed Care Organization)
Harmony Health Plan (MCO – Managed Care Organization)
Illinicare Health (MCO – Managed Care Organization)
Meridian Health Plan (MCO – Managed Care Organization)
Molina Healthcare (MCO – Managed Care Organization)
NextLevel Health Partners (MCO – Managed Care Organization)
Private Insurance (HMO/PPO)
Other*
Medicaid/Insurance ID Number
Best Call Back Number *
Best Call Back Time
Preferred Language
Select Language
Afrikaans
Albanian
Arabic
Armenian
Azerbaijani
Basque
Belarusian
Bengali
Bosnian
Bulgarian
Burmese
Catalan
Cebuano
Chichewa
Chinese (Simplified)
Chinese (Traditional)
Corsican
Croatian
Czech
Danish
Dutch
Esperanto
Estonian
Filipino
Finnish
French
Frisian
Galician
Georgian
German
Greek
Gujarati
Haitian Creole
Hausa
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Icelandic
Igbo
Indonesian
Irish Gaelic
Italian
Japanese
Javanese
Kannada
Kazakh
Khmer
Korean
Kurdish (Kurmanji)
Kyrgyz
Lao
Latin
Latvian
Lithuanian
Luxembourgish
Macedonian
Malagasy
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Nepali
Norwegian
Pashto
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Scots Gaelic
Serbian
Sesotho
Shona
Sindhi
Sinhala
Slovak
Slovenian
Somali
Spanish
Sundanese
Swahili
Swedish
Tajik
Tamil
Telugu
Thai
Turkish
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Yiddish
Yoruba
Zulu
Submit
Income Guidelines
Household Size
1
2
3
4
5
6
7
8
30 Day Gross Income
$2,265
$3,052
$3,838
$4,625
$5,412
$6,198
$6,985
$7,324
LIHEAP ELIGIBILITY REQUIREMENTS
First Name
Enter Your Lastname
Email
Social Security
Address
street address line 2
City
State / Province
Postal / Zip Code
Phone Number
Date
First Time Applying For CEDA?
Yes
No
Gas Type
Heating
Non-Heating
On whose name Gas Bill is?
Date of most recent Gas Bill?
ComED Account Number
On whose name ComEd Bill is?
Date of most recent ComEd Bill?
Housing Type
Rent
Own
How many Bedroom
One
Two
Dwelling Type
Single Family House
1Unit
Rent Amount
AC Type
Central
Window
Ethnic Group
White
African American
Type of Income
Employment
Self-Employment
last 30 days Income
Date of most recent paystub
If no income, how is financially supporting the family?
SNAP Benefit
Yes
No
Medicaid
Yes
No
Number of people in the House in the household
Please specify the Name, Date of Birth, Social Security, and Income of each family member.
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