Welcome to IDHS FOID Mental Health Reporting System

Validation Errors:

Facility Type is required
Street Address 1 is required
City is required
State is required
Zip Code is required
Adminstrator First Name is required
Adminstrator Last Name is required
Adminstrator Phone Number must be a number and not be 10 characters
Adminstrator Phone Number must be a number and not be 10 characters
Adminstrator E-Mail Address is required
Primary Contact First Name is required
Primary Contact Last Name is required
Primary Contact Phone Number must be a number and not be 10 characters
Primary Contact Phone Number must be a number and not be 10 characters
Primary Contact E-Mail Address is required

Facility Registration

Please provide the information below:

*Facility Name:

*Facility Type:

*Address:

Address 2:

*City:

*State:

*Zip:

-

Ext:

Administrator Information:

*First Name:

Middle Name:

*Last Name:

*Phone:
() -

Ext:

*E-Mail Address:

*Confirm E-Mail Address:

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

Check here to retain Administrator Information for Primary Contact.

Primary Contact Information:

*First Name:

Middle Name:

*Last Name:

*Phone:
() -

Ext:

*E-Mail Address:

*Confirm E-Mail Address:

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

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