[North Los Angeles County Regional Center] Early Start Application

North Los Angeles County Regional Center

Early Start Application

For Children under Age 3

First Name of Child

Middle Name of Child

Last Name of Child

Birth Date of Child

Age of Child in Months

Birth Place of Child

Gender of Child (Sex Assigned at Birth)

Social Security Number of Child

Ethnicity of Child

Preferred Language for Communication with Regional Center

Other Languages Spoken

Has the child's name been changed?

Yes

Previous First Name of Child

Previous Middle Name of Child

Previous Last Name of Child

Primary Residence of Child:

Who does the Child live with?

Street Address

City

State

Zip Code

Primary responsible party who can be contacted regarding this application

Responsible Party First Name

Responsible Party Last Name

Relationship of Responsible Party to Child

Responsible Party Primary Phone Number

Responsible Party Email

Is the child in foster care?

Yes

Holder of Educational Rights for the Child

Social Worker / DCFS Name

Social Worker / DCFS Phone Number

Social Worker / DCFS Email

Were you referred to us by an agency, health care provider, preschool, or other professional or individual?

Yes

Referral by

Referral Phone Number

Referral E-mail / Fax

Has the child previously received assessment or services from the North Los Angeles County Regional Center or another Regional Center?

Yes

If "Yes," please name the Regional Center

Parent 1 Information:

Parent 1 First Name

Parent 1 Middle Name

Parent 1 Last Name

Relationship of Parent 1 to Child

Does the Parent 1 live with the Child?

Parent 1 Birth Date

Parent 1 Birth Place

Parent 1 Preferred Language

Parent 1 Street Address

Parent 1 City

Parent 1 State

Parent 1 Zip Code

Parent 1 Email

Parent 1 Phone Number

Parent 1 Employer Name

Parent 1 Job Title

Is Parent 1 Disabled?

Yes

Parent 1 Marital Status

Is there a second parent?

Parent 2 Information:

Parent 2 First Name

Parent 2 Middle Name

Parent 2 Last Name

Relationship of Parent 2 to Child

Does the Parent 2 live with the Child?

Parent 2 Birth Date

Parent 2 Birth Place

Parent 2 Preferred Language

Parent 2 Street Address

Parent 2 City

Parent 2 State

Parent 2 Zip Code

Parent 2 Email

Parent 2 Phone Number

Parent 2 Employer Name

Parent 2 Job Title

Is Parent 2 Disabled?

Yes

Parent 2 Marital Status

Is there an additional parent?

Parent 3 Information:

Parent 3 First Name

Parent 3 Middle Name

Parent 3 Last Name

Relationship of Parent 3 to Child

Does the Parent 3 live with the Child?

Parent 3 Birth Date

Parent 3 Birth Place

Parent 3 Preferred Language

Parent 3 Street Address

Parent 3 City

Parent 3 State

Parent 3 Zip Code

Parent 3 Email

Parent 3 Phone Number

Parent 3 Employer Name

Parent 3 Job Title

Is Parent 3 Disabled?

Yes

Parent 3 Marital Status

Health Care Provider Information For Record Request
Please indicate the name and contact information, as applicable, for the current physician, any medical specialist, hospital, psychologist or mental health provider.

This infomation will be used by NLACRC to create consent forms for your signature in order to request information.

Provider 1 - Birth Hospital or NICU

Provider 1 Name

Provider 1 Type

Provider 1 Phone Number

Would you like to add a second Provider?

Yes

Provider 2 - Doctor, Health Care Provider

Provider 2 Name

Provider 2 Type

Provider 2 Phone Number

Would you like to add a third Provider?

Yes

Provider 3 - Doctor, Health Care Provider

Provider 3 Name

Provider 3 Type

Provider 3 Phone Number

Would you like to add a fourth Provider?

Yes

Provider 4 - Doctor, Health Care Provider

Provider 4 Name

Provider 4 Type

Provider 4 Phone Number

Would you like to add a fifth Provider?

Yes

Provider 5 - Doctor, Health Care Provider

Provider 5 Name

Provider 5 Type

Provider 5 Phone Number

Please upload copy of insurance card, medical records, psychological assessment, and any relevant documents

Upload File(s)

Click Here to Upload

If you are not registered to vote where you live now, would you like to apply to register to vote?

NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

If you are interested in registering to vote, we will follow up with you further to provide additional information.

Voter Registration Preference

Already registered. I am registered to vote at my current residence address

Yes. I would like to register to vote

No. I do not want to register to vote

Important Notices

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration form in private.
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or other political preference, you may file a complaint with the Secretary of State by calling toll-free (800) 345-VOTE (8683) or you may write to: Secretary of State, 1500 - 11^th Street, Sacramento, CA, 95814. For more information on elections and voting, please visit the Secretary of State’s website at www.sos.ca.gov.

Consent for Evaluation and Release of Information

Purpose: The purpose of this form is to allow North Los Angeles County Regional Center (“NLACRC”) to obtain consent to perform an evaluation on your child’s eligibility for California’s Early Start Program.

Scope: By signing below, you allow NLACRC to perform this Early Start Program evaluation, which will include gathering and assessing your child’s health and other developmental milestone information (from birth to present) that may include collaboration with one or more NLACRC vendored service providers to support NLACRC in completing this evaluation.

About the Evaluation: By signing below, you agree for NLACRC to learn about and gather information about your child’s development, which will include requesting health records from third parties, talking to you about your child’s developmental milestones, observing your child at home or other similar environments, and reviewing your child’s medical and/or other similar records. The collective information gathered will assist NLACRC in determining whether your child is eligible for California's Early Start Program, and if so, further help us to identify the type of early intervention services needed for your child.

What Signing Below Means: By signing below, you understand and agree to the following:

Your written consent to perform this evaluation is entirely voluntary, valid for two (2) year from the date shown below and may be withdrawn at any time.
Your written consent is required by NLACRC to determine Early Start eligibility.
Your child’s Early Start evaluation will be completed promptly and performed in your and your child’s primary language or preferred language choice.
You have the right to review, inspect and request a copy of your child’s records.
All records gathered regarding your child will be kept strictly confidential in accordance with the HIPAA and other applicable California privacy laws.
NLACRC will complete a developmental evaluation in all five (5) developmental domains to help determine if your child is eligible or continues to be eligible for Early Intervention services.
NLACRC will release personally identifiable information regarding your child to an NLACRC vendored service provider(s) for the purpose of conducting an Early Start evaluation. This information will include, but is not limited to, your child’s name, date of birth, home address, telephone number(s), and other similar information.

ADDITIONAL CONSENT TO RELEASE MY CHILD’S INFORMATION TO GENERIC RESOURCES

By signing below, I authorize NLACRC to refer my child, as deemed appropriate by NLACRC, to one or more generic resource agencies for potential future assistance with my child’s condition(s). These generic resource agencies include the Family Focus Resource Center, California Children Services, and Early Head Start. Please note that this referral process will comply with all HIPAA and other applicable Federal and California privacy laws.

Notice of Privacy Practices Acknowledgement

I understand that all information and records obtained by the North Los Angeles County Regional Center in the course of providing intake and assessment services are confidential.

Please review the enclosed Notice of Privacy Practices by clicking this link https://nlacrc.seamlessdocs.com/f/ESNoticeofPrivacyEN. Please be advised this link will open a new screen. Please make sure to return to this screen to finalize the appliction.

By signing this form, I acknowledge that I was provided a copy of the Notice of Privacy Practices of the North Los Angeles County Regional Center. I acknowledge that I have read (or had the opportunity to read) and understood the Notice. I understand that I can request a paper copy of the Notice at any time.

Name of Child

Child Birth Date

Signer Relationship to Child

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign this form and I hereby consent to the assessment of the individual named on this form for the purpose of determining eligibility for Regional Center services.