[North Los Angeles County Regional Center] Intake Application

North Los Angeles County Regional Center

Intake Application

For Children over Age 3 and Adults

Applicant First Name

Applicant Middle Name

Applicant Last Name

Applicant Birth Date

Applicant Age

Applicant Birth Place

Applicant Gender (Sex assigned at birth)

Applicant Preferred Gender Pronoun

Applicant Social Security Number

Applicant Ethnicity

Applicant Marital Status

Preferred Language for Communication with Regional Center

Other Languages Spoken

Has the Applicant's name been changed?

Yes

Applicant Previous First Name

Applicant Previous Middle Name

Applicant Previous Last Name

Applicant Primary Residence:

Who does the Applicant live with?

Applicant Street Address

Applicant City

Applicant State

Applicant Zip Code

Applicant Primary Phone Number

Applicant Email

Primary responsible party who can be contacted regarding this application

Responsible Party First Name

Responsible Party Last Name

Relationship of Responsible Party to Applicant

Responsible Party Primary Phone Number

Responsible Party Email

Is the applicant 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, school, or other professional or individual?

Yes

Referral by

Referral Phone Number

Referral E-mail / Fax

Has the applicant 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 Applicant

Does the Parent 1 live with the Applicant?

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 Applicant

Does the Parent 2 live with the Applicant?

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 Applicant

Does the Parent 3 live with the Applicant?

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

1. Medical History

Does the applicant have any medical diagnoses or chronic health conditions?

Yes

Please describe Medical History:

Physician Name (Medical)

Please list any medications that the applicant is currently taking for his/her medical condition.

2. Mental Health History

Does the applicant have a current mental health (psychiatric) diagnosis?

Yes

Please describe Mental Health (psychiatric) history:

Mental Health provider name

Please list any medications that the applicant is currently taking for his/her mental health (psychiatric) condition:

3. School History

Name of current school or last school attended before age 18 (If not in school or school is unknown, please indicate)

Phone number of current or last school attended

Is the applicant currently or previously been in a special education program or had an IEP (Individualized Education Program)? If yes, please submit copy of your current IEP.

Yes

Insurance Information

IMPORTANT: Please upload a copy of the applicant's insurance card at the end of this application.

Health Insurance

Medi-Cal

Private Insurance

No Insurance

Insurance Company Name

Insurance Policy Number

Health Care Provider / Additional School 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, and additional schools attended.

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

Provider 1 - Doctor, Other Health Care Provider or Additional School Information

Provider 1 Name

Provider 1 Type

Provider 1 Phone Number

Would you like to add another Health Care Provider or Additional School Information?

Yes

Provider 2 - Doctor, Health Care Provider or Additional School Information

Provider 2 Name

Provider 2 Type

Provider 2 Phone Number

Would you like to add another Health Care Provider or Additional School Information?

Yes

Provider 3 - Doctor, Health Care Provider or Additional School Information

Provider 3 Name

Provider 3 Type

Provider 3 Phone Number

Would you like to add another Health Care Provider or Additional School Information?

Yes

Provider 4 - Doctor, Health Care Provider or Additional School Information

Provider 4 Name

Provider 4 Type

Provider 4 Phone Number

Would you like to add another Health Care Provider or Additional School Information?

Yes

Provider 5 - Doctor, Health Care Provider or Additional School Information

Provider 5 Name

Provider 5 Type

Provider 5 Phone Number

Please upload copy of insurance card, medical records, psychological assessment, school records (IEP) 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 Intake and Assessment Services

By signing this form, I hereby consent to the assessment of the individual named on this form for the purpose of determining eligibility for Regional Center services as per the Lanterman Developmental Disability Services Act. I understand that assessment may include collection and review of available historical diagnostic information, provision or procurement of necessary tests and evaluations and summarization of developmental levels and service needs. I understand that the North Los Angeles County Regional Center may consider evaluations and tests, including, but not limited to, intelligence tests, adaptive functioning tests, neurological and neuropsychological tests, diagnostic tests performed by a physician, psychiatric tests, and other tests and evaluations that have been performed by, and are available from, other sources. (California Welfare and Institutions code Section 4642, 4653)

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/NoticeofPrivacyEN. 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.

Consumer Rights Complaint Process

Consumers and their families have a legal right to file a complaint if they feel their rights have been violated or unreasonably denied.

Please review the Consumer Rights Complaint Process by clicking this link https://www.nlacrc.org/consumers-families/complaint-process or https://nlacrc.seamlessdocs.com/f/RightsComplaint. Please be advised this link will open a new screen. Please make sure to return to this screen to finalize the appliction.

Name of Applicant

If Applicant is a minor or unable to sign, please indicate relationship

Signer relationship to Applicant

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.