Regional center intake application 2025

1. Click ‘Get Form’ to open the regional center intake application in the editor.
2. Begin by entering the applicant’s name in the designated fields for Last, First, and Middle names. Ensure accuracy as this information is crucial for identification.
3. Fill in the Date of Birth using the MM/DD/YY format. Select the appropriate gender option by clicking on either Male or Female.
4. Provide the Social Security Number (SSN) and select the applicant's ethnicity from the provided list. If applicable, specify any additional ethnic backgrounds.
5. Indicate the primary language spoken by checking the relevant box. This helps ensure effective communication during services.
6. Complete the insurance section by checking all applicable options and providing plan names. Remember to include Medi-Cal and Medicare numbers if available.
7. Fill out parent/legal guardian information, including names, relationship to applicant, addresses, and contact numbers.
8. In the alternate contact section, provide details of another person who can be reached regarding the applicant.
9. Outline your concerns and reasons for referral in the designated area. Be concise yet thorough to assist in understanding your needs.
10. Attach any relevant documents that support your application, such as medical records or educational plans. If you have no records for a child under five, indicate this clearly.
11. Finally, review all entered information for accuracy before submitting via email or fax as instructed at the end of the form.

Start filling out your regional center intake application online for free today!