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Lanterman Act Referral Form

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.
  • MM slash DD slash YYYY
  • Reason for Referral & Additional Information Attachments

  • Drop files here or
    Max. file size: 100 MB.
    • Which of these eligible conditions do you feel applies to the applicant?

    • APPLICANT’S KNOWN OR SUSPECTED CONDITIONS

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

      If no, skip the section 1.
    • (2) Autism (if no skip section #2)

      If no, skip the section 1.
    • (3) Cerebral Palsy (if no skip section #3)

    • (4) Epilepsy

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

    • APPLICANT’S MEDICAL HISTORY

    • Max. file size: 100 MB.
    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • APPLICANT’S MENTAL HEALTH HISTORY

    • MM slash DD slash YYYY
    • APPLICANT’S EDUCATIONAL HISTORY

    • MM slash DD slash YYYY
    • OTHER SERVICES

    • MM slash DD slash YYYY
    • MM slash DD slash YYYY
    • An Intake Specialist/Coordinator will call you as soon as possible to discuss the next steps of the intake process. When you have obtained copies of your records/reports that are helpful to us, you can forward them to:

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