DMH Waiver Variety is required to provide its funding partners with the status of program participants who receive funding through the Department of Mental Health waivers.Participant Name(Required) First Last Please select if the Variety participant has any of these DMH funding sources.(Required) Community Support Waiver Partnership for Hope Waiver MOCDD (Sarah Lopez) Waiver Comprehensive Waiver No, the participant does not receive any of the above funding HiddenDoes the Variety participant receive funding through the Department of Mental Health EMAP program or one of the Department of Mental Health waivers, including Partnership for Hope, Community Support, or MOCDD (Sarah Lopez)? Yes No County(Required)CountyCrawford, MOFranklin, MOGasconade, MOIron, MOJefferson, MOLincoln, MOPerry, MOPike, MOSt. Charles, MOSt. Francois, MOSt. Genevieve, MOSt. Louis City, MOSt. Louis County, MOWarren, MOWashington, MOBond, ILCalhoun, ILClay, ILClinton, ILFayette, ILGreene, ILJersey, ILMacoupin, ILMadison, ILMarion, ILMonroe, ILMontgomery, ILRandolph, ILSt. Clair, ILWashington, ILNature of Request(Required) Medical Equipment Therapy Services Both Equipment and Therapy DMH Service Coordinator's Name(Required) First Last PhoneEmail Δ
