Lanterman Act Referral Form

This form is not an application but it is used by the VMRC Referral Specialist in processing your eligibility application. Our regional center receives a high volume of intake referral forms so please expect about 3 weeks between submitting this form and receiving a call back from us to engage you further in the application process.

Form Completed By (if different from referral source):

First Last

Applicant's First Name*

First

Last Name*

AKA

First Last

Date of Birth*

Age*

Primary Contact Phone (Person to Schedule With)

Child Social Security Number

Birthplace (Include City, State)

Ethnicity

Gender

Primary Language of Family

Interpreter Needed?

Yes
No

Applicant Email (If Adult)

Applicant Phone (If Adult)

Applicant's Home Address*

Street Address Address Line 2 City State ZIP Code

Living

YES

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Mother's Name

First Last

Living

YES

Date of Birth

Lives with Applicant

Yes
No

Highest Level of Education

Mother's Email

Mother's Phone

Mother's Job

Father's Name

First Last

Living

YES

Date of Birth

Lives with Applicant*

Yes
No

Highest Level of Education

Father's Email

Father's Phone

Father's Job

Foster Parent (if applicant does not live with the biological parent)

First Last

Foster Parent Mailing Address

Street Address Address Line 2 City State ZIP Code

Relation to applicant (such as grandparent, aunt, uncle, etc.)

Foster Parent Phone Number

Foster Parent Email

Social Worker Name

First Last

Social Worker Email

Social Worker Phone Number

Social Worker Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who referred you to VMRC?

First Last

Referring Party Agency Name

Agency Name

Referring Party Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referring Phone Number

Referral Person's Email

Relationship to Applicant

Reason for Referral & Additional Information Attachments

Please type reason for referral*

Please provide diagnostic reports, IEPs, psychoeducational assessment, and medical records. You may upload, mail or fax to (209)956-6439. This is especially important for applicants over the age of 18

Attach Files Here

Accepted file types: pdf, png, gif, jpg, docx, doc, Max. file size: 99 MB.

Attach Additional Files Here

Accepted file types: pdf, png, gif, jpg, docx, doc, Max. file size: 99 MB.

Attach Additional Files Here

Accepted file types: pdf, png, gif, jpg, docx, doc, Max. file size: 99 MB.

Which of these eligible conditions do you feel applies to the applicant?

Please check one or more.

Intellectual Disability (or something closely related)
Autism
Epilepsy
Cerebral Palsy

APPLICANT’S KNOWN OR SUSPECTED CONDITIONS

(1) Intellectual Disability (if no skip section #1)

Has the applicant been diagnosed by a professional with Intelectual Disability?

Yes
No

Professional's Name

First Last

At what age was applicant first diagnosed?

Please describe concerns about the applicant’s ability to learn:

Please describe concerns about applicant’s ability to perform age-appropriate skills independently:

(2) Autism (if no skip section #2)

Has the applicant been diagnosed by a professional with Autism?

Yes
No

Professional's Name

First Last

At what age was applicant first diagnosed?

Please describe concerns about the applicant’s communication skills:

Please describe concerns about applicant’s Social Interactions:

Please describe concerns about applicant’s Repetitive behaviors and/or restricted interests:

(3) Cerebral Palsy (if no skip section #3)

Has the applicant been diagnosed by a medical professional with Cerebral Palsy?

Yes
No

Professional's Name

First Last

At what age was applicant first diagnosed?

Does the applicant use adaptive equipment?

How does Cerebral Palsy affect the applicant's physical functioning?

(4) Epilepsy

Has the applicant been diagnosed by a medical professional with Cerebral Palsy?

Yes
No

Professional's Name

First Last

At what age was applicant first diagnosed?

Is applicant taking medicine for Epilepsy (seizures)?

Yes
No

If yes, please list the medication(s) used for Epilepsy (seizures):

Type(s) of seizures:

Age seizures first started:

How frequent are the seizures?

Describe how the applicant is impacted in daily functioning by seizures:

(5) Disabling conditions found to be closely related to intellectual disability or requiring treatment similar to that required for individuals with intellectual disability.

Is the applicant suspected of having a disabling condition that is closely related to intellectual disability (such as Borderline Intellectual Functioning) or requiring treatment similar to that required for individuals with intellectual disability? (if no skip section #5)

Yes
No

Please describe concerns about the applicant’s ability to learn: Please describe concerns about applicant’s ability to perform age-appropriate skills independently:

DEVELOPMENTAL HISTORY

Sitting (Age in Months)

Crawling (Age in Months)

Walking (Age in Months)

Single Words (Age in Months)

Paired Words (Age in Months)

Toilet Training (Age in Months)

APPLICANT’S MEDICAL HISTORY

Insurance

Private Insurance
Managed Care/MEDI-CAL
Straight MEDI-CAL
No Insurance

Name of current Health Insurance*

Insurance Number

Upload Health Insurance Card

Max. file size: 100 MB.

Name of Primary Care Physician:

First Last

Address of Primary Care Physician

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List of Current Medications:

List major injury or illness?

List Any Surgery

List Any Hospitalization

Any history of Traumatic Brain Injury (TBI)

Any genetic testing done?

Yes
No

Date of genetic testing done?

Any hearing tests done?

Yes
No

Date of hearing tests done?

APPLICANT’S MENTAL HEALTH HISTORY

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

Yes
No

If yes, what is the applicant’s diagnosis(es)?

Date of diagnosis(es)/evaluation(s)?

Name(s) and address(es) of Mental Health provider(s) that the applicant is/was receiving services from:

APPLICANT’S EDUCATIONAL HISTORY

Current School of Attendance (If Adult Last School Attended)?

Current Grade:

Does the applicant have an Individualized Education Program (IEP)?

Yes
No

Primary Disability in the IEP

Secondary Disability in the IEP

In what grade did the applicant start receiving Special Education services?

Did the applicant graduate from High school?

Yes
No

Applicant received a

Diploma
or Certificate of Completion

Date Received

OTHER SERVICES

Has the applicant received services through the Department of Rehabilitation(DOR)?

Yes
No

If “yes” then provide the name and address of the worker

If yes, when was the case open?

Has applicant received services though Child Protective Services (CPS)?

Yes
No

If yes, when was the case open?

If “Yes” then provide the name and address of the worker:

Is the applicant receiving SSI benefits?

Yes
No

Were any services for applicant’s developmental disability received from out State of California?

Yes
No

Which State(s)?

Name and address of the agencies that provided developmental services out of California:

Consent to the Assessment

I agree to consent

By checking this box, I acknowledge that I am the applicant or parent of the applicant (under age 18), 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 Valley Mountain 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)

I understand that all information and records obtained by the Valley Mountain Regional Center in the course of providing intake and assessment services are confidential.

This form is not an application, but it is used by the VMRC Referral Specialist in processing your eligibility application. Our regional center receives a high volume of intake referral forms so please expect about 3 weeks between submitting this form and receiving a call back from us to engage you further in the application process.

Select the nearest Valley Mountain Regional Center office*

San Andreas County Office Phone: (209) 754-1871 fax# (209) 754-3211
San Joaquin County Office Phone: (209) 473-0951 fax# (209) 956-6439
Stanislaus County Office Phone: (209) 529-2626 fax# (209) 552-7578