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adult services application Looking for something?

Please review the booklet, “Making It Happen: Harbor Regional Center Applicant Information,” which is linked to the application for services page of this website. If after reading the brochure you would like to proceed with an application, please enter the applicant information below. The information provided will be kept confidential. You will hear back from an Intake Counselor within two working days after submitting this internet application. If you would like to speak with an Intake Counselor, the direct number is 310-543-7928.
applicant information
Full Name:
Primary Language:
Birthdate: (e.g. mm/dd/yyyy)
Street Address:
City:
State: Zip:
Phone Number: (e.g. 310-540-1711)
Email Address:
Please provide the name of a parent, conservator, or other adult who will be the contact person, if any:
Relationship to applicant
Contact Person Primary Phone:
Contact Person Email Address:
Best Time to Reach Contact Person:
questionnaire
Was the applicant ever evaluated by a regional center?
Yes   No
What was the outcome of this evaluation? Was he or she found eligible for regional center services?
Has applicant been given a diagnosis of a developmental disability (such as mental retardation/intellectual disability, autism, cerebral palsy, epilepsy)? If so, what diagnosis was given?
Does the applicant receive SSI?
Yes   No
Does the applicant receive MediCal? If so, please enter MediCal number here:
Does the applicant have other health insurance coverage? Please enter the name of the insurance company and policy number:
Has the applicant attended Special Education Programs in school?
Yes   No
Please list schools attended by the applicant, dates, and whether or not this was a special education program:
Has the applicant ever been employed?
Yes   No
If yes, please list recent job(s) held and approximate dates:
Is the applicant receiving mental health services?
Yes   No
Please describe the applicant's condition and why you believe he or she might qualify for regional center services:
 
Required
making sure that our clients and families have access to the services and supports they need
making sure that our clients and families have access to the services and supports they need
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Last Update: Saturday, February 04, 2012
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