Service Provider Forms

Parental Verification of Receipt of Services


Section 4681.31 of the Welfare and Institutions Code requires any vendor who provides  services as specified below to submit verification to the regional center for services provided to individuals who are under 18 years of age and residing in the family home.

The Department of Developmental Services has developed a standard form for vendors to complete and provide to the family for signature. 

This requirement applies to the following types of services: Behavior Analyst, Associate Behavior Analyst, Behavior Management Assistant, Behavior Technician Paraprofessional), Behavior Management Consultant, Counseling Services, Tutor, Crisis Team-Evaluation and Behavioral Intervention, Tutor Services-Group, Client/Parent Support Behavior Intervention Training, and Parent-Coordinated Home Based Behavior Intervention Program for Autistic Children.

Download Forms for Behavior Intervention, PT, OT, and Speech

Parental Verification for receipt of Behavioral Services

Individual Direct Service Log PDF

Individual Direct Service Log Word

Group Service Log PDF

Group Service Log Word

Department of Developmental Services Letter_Parental Verification