Welcome to IDHS FOID Mental Health Reporting System

Please Note: Submitting a report without registering for a user account will require entering demographic information each time a report is made. Information on the report cannot be edited after the report has been submitted. If any information requires editing, please E-Mail DHS.FOID@Illinois.gov for assistance.

Please Enter Your Information Below:

* First Name:

Middle Name:

* Last Name: (Exactly as listed on your license through IDFPR) :

* Last 4 Digits of SSN:

* Medical or Professional License Number (enter 8 or 9 numeric characters exactly as it appears on your IDFPR license, no dashes, no periods):

* Work Phone:
() -

Ext:

* Work E-Mail:

* Confirm Work E-Mail:

* Full Practice or Facility Name :

* Work Address:

Work Address2:

* Work City:

* State:

*Zip:

Ext:

* License Type:

Please Enter Patient Information below:

*First Name:

Middle Name:

*Last Name:

Suffix:

Medical Record Number :

Contact Serial Number:

Leave Social Security Number field blank if unknown. Do not submit fake social security numbers.

Social Security Number:

*Date of Birth:(mm/dd/yyyy)

Homeless You will not be able to enter address below if this Homeless Indicator is checked.

*Address:

Address 2:

*City:

*State:

*Zip:

Ext:

*Gender:

*Race:

Eye Color:

Hair Color:

Height(feet) & Height(inches):

Weight(pounds):

* Event Type(Choose all that apply):
Clear and Present Danger Developmental Disability (Substantial functional limitations in 3 or more areas of major life activity. Full definition in the Firearm Owners Identification Card Act. (430 ILCS 65/1.1)) Intellectual Disability(Significantly subaverage general intellectual functioning. Full definition in the Firearm Owners Identification Card Act. (430 ILCS 65/1.1))

* Clear and Present Danger(choose all that apply)

* a) Communicates a serious threat of physical violence against a reasonably identifiable victim or poses a clear and imminent risk of serious physical injury to himself, herself, or another person as determined by a physician, clinical psychologist, advanced practice psychiatric nurse, or qualified examiner

* b) Demonstrates threatening physical or verbal behavior, such as violent, suicidal, or assaultive threats, actions, or other behavior, as determined by a physician, clinical psychologist, advanced practice psychiatric nurse, qualified examiner, school administrator, or law enforcement official

*Clear and Present Danger Event Date: (mm/dd/yyyy)

*Please briefly describe how and why you have determined this person is a Clear and Present Danger:

500 characters left

*Determination Date of Developmental Disability: (mm/dd/yyyy)

*Please briefly describe how you made the determination of this disability:

500 characters left

*Determination Date of Intellectual Disability: (mm/dd/yyyy)

*Please briefly describe how you made the determination of this disability:

500 characters left

*Please enter security code in this text box: -->