Welcome to IDHS FOID Mental Health Reporting System

Qualified Examiner Registration

Please Enter Qualified Examiner Information below

* Qualified Examiner First Name:

Qualified Examiner Middle Name:

* Qualified Examiner Last Name (enter exactly as spelled on Qualified Examiner License):

* Last 4 Digits of SSN:

* Qualified Examiner License Number (enter 8 or 9 numeric characters exactly as it appears on Qualified Examiner License, no dashes, no periods):

* Qualified Examiner Work Phone:
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* Qualified Examiner Work E-Mail:

* Confirm Work E-Mail:

Note: Your E-Mail address will be your User ID

* Qualified Examiner Practice Name (where person presented):

* Qualified Examiner Work Address:

Qualified Examiner Work Address2:

* Qualified Examiner Work City:

* State:

*Zip:

Ext:

* Qualified Examiner Referral Method:

* Qualified Examiner Type:

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