Lanterman Act Referral Form -Valley Mountain Regional Center

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 Name(Required)

First Last

AKA

First Last

Date of Birth(Required)

Age(Required)

Primary Contact Phone (Person to Schedule With)

Child Social Security Number

Birthplace (Include City, State)

Ethnicity

Gender

Primary Language of Family

Interpreter Needed?

Yes

Applicant Phone (If Adult)

Applicant Email (If Adult)

Applicant's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Living

Yes

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Parent Relationship status

Married

Living Together / Domestic Partners

Never Married / Single

Divorced

Separated

Widowed

Is there a legal custody agreement(Required)

Yes

File

Max. file size: 100 MB.

Mother's Name

First Last

Living

Yes

Legal Guardian(Required)

Yes

Date of Birth

Lives with Applicant

Yes

Highest Level of Education

Mother's Email

Mother's Phone

Mother's Job

Father's Name

First Last

Living

Yes

Legal Guardian(Required)

Yes

Date of Birth

Lives with Applicant(Required)

Yes

Highest Level of Education

Father's Phone

Father's Email

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 Phone Number

Social Worker Email

Social Worker Address

Street Address Address Line 2 City State ZIP Code

Who referred you to VMRC?

First Last

Referring Party Agency Name

Referring Party Address

Street Address Address Line 2 City State ZIP Code

Referring Phone Number

Referral Person's Email

Relationship to Applicant

Reason for Referral & Additional Information Attachments

Please type reason for referral(Required)

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

Drop files here or

Max. file size: 100 MB.

Attach Additional Files Here

Max. file size: 100 MB.

Attach Additional Files Here

Max. file size: 100 MB.

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

Intellectual Disability (or something closely related)

Autism

Epilepsy

Cerebral Palsy

Please check one or more.

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

Intellectual Disability

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

Autism

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

Cerebral Palsy

Professional's Name

First Last

At what age was applicant first diagnosed?

Does the applicant use adaptive equipment?

Other

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

(4) Epilepsy

Has the applicant been diagnosed by a medical professional with Epilepsy?

Yes

Epilepsy

Professional's Name

First Last

At what age was applicant first diagnosed?

Is applicant taking medicine for Epilepsy (seizures)?

Yes

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

Disabling conditions

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

Insurance Details

Name of current Health Insurance(Required)

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

Date of genetic testing done?

Any hearing tests done?

Yes

Date of hearing tests done?

APPLICANT’S MENTAL HEALTH HISTORY

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

Yes

Psychiatric Diagnosis

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

Education Program

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

Applicant received a

Diploma

or Certificate of Completion

Date Received

OTHER SERVICES

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

Yes

DOR Detail

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

If yes, when was the case open?

CPS SERVICES

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

Yes

CPS Detail

If yes, when was the case open?

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

SSI Services

Is the applicant receiving SSI benefits?

Yes

Out of State

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

Yes

Out of State Details

Which State(s)?

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

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.

VMRC Office Locations

Select the nearest Valley Mountain Regional Center office(Required)

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

After you click “Submit”, print or screen shot the confirmation page that appears for your records.

Lanterman Act Referral Form

Lanterman Act Referral Form Update

Reason for Referral & Additional Information Attachments

APPLICANT’S KNOWN OR SUSPECTED CONDITIONS

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

Intellectual Disability

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

Autism

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

Cerebral Palsy

(4) Epilepsy

Epilepsy

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

Disabling conditions

DEVELOPMENTAL HISTORY

APPLICANT’S MEDICAL HISTORY

Insurance Details

APPLICANT’S MENTAL HEALTH HISTORY

Psychiatric Diagnosis

APPLICANT’S EDUCATIONAL HISTORY

Education Program

OTHER SERVICES

DOR Detail

CPS SERVICES

CPS Detail

SSI Services

Out of State

Out of State Details

VMRC Office Locations