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.Applicant's First Name* First Last Name* AKA First Last Applicant's Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age*Date of Birth* MM slash DD slash YYYY GenderFemaleMaleOther/UnknownEthnicity 2 – African American/Black I – Asian Indian B – Cambodian C – Chinese 3 – Filipino G – Guamanian M – Hmong J – Japanese K – Korean L – Laotian 4 – Native American H – Native Hawaiian 8 – Other A – Other Asian P – Other Pacific Islander R – Russian S – Samoan 6 – Spanish/Latin T – Thai 9 – Unknown V – Vietnamese 7 – White Primary Language of FamilyEnglishSpanishOther LanguageInterpreter Needed? Yes No Medication (include dose and type of medication)Mother's Name First Last Lives with Applicant Yes No Email PhoneMother's Job Father's Name First Last Lives with Applicant* Yes No Email PhoneFather's Job Foster Parent (if applicant does not live with the biological parent) First Last Relation to applicant (such as grandparent, aunt, uncle, etc.) Lives with Applicant Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Phone NumberEmail Who referred you to VMRC? First Last Referring Party Agency Name Agency Name Referring Party Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberReferral Person's Email Relationship to ApplicantParentFamily MemberSchoolDoctorHospitalCPSAPSMental HealthOther Community AgenciesForm Completed By (if different from referral source): First Last Reason for Referral & Additional Information AttachmentsPlease type reason for referral*Attached Files Drop files here or Select files Max. file size: 100 MB. Which of these eligible conditions do you feel applies to the applicant?Please check one or more.* Intellectual Disability (or something closely related) Autism Epilepsy Cerebral Palsy APPLICANT’S KNOWN OR SUSPECTED CONDITIONS(1) Intellectual Disability (if no skip section #1)Is the applicant suspected of having Intellectual Disability? Yes No If no, skip the section 1. Has the applicant been diagnosed by a professional with Intelectual Disability? Yes No 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)Is the applicant suspected of having Autism (Autism Spectrum Disorder)? Yes No If no, skip the section 1. Has the applicant been diagnosed by a professional with Autism? Yes No 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)Is the applicant suspected of having Cerebral Palsy? Yes No Has the applicant been diagnosed by a medical professional with Cerebral Palsy? Yes No Professional's Name First Last At what age was applicant first diagnosed? Does the applicant use adaptive equipment? None Wheelchair Walker AFO/Brace Other How does Cerebral Palsy affect the applicant's physical functioning?*(4) EpilepsyIs the applicant suspected of having Epilepsy? (if no skip section #4) Yes No Has the applicant been diagnosed by a medical professional with Cerebral Palsy? Yes No Professional's Name First Last At what age was applicant first diagnosed? Is applicant taking medicine for Epilepsy (seizures)? Yes No If yes, please list the medication(s) used for Epilepsy (seizures): Type(s) of seizures: Age seizures first started: How frequent are the seizures? None in past year Daily Weekly Monthly Yearly 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 No Please describe concerns about the applicant’s ability to learn: Please describe concerns about applicant’s ability to perform age-appropriate skills independently:*APPLICANT’S MEDICAL HISTORYInsurance Private Insurance Managed Care/MEDI-CAL Straight MEDI-CAL No Insurance Name of current Health Insurance* Insurance NumberUpload Health Insurance CardMax. 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country List of Current Medications: Major Injury or illnesses: Yes No Type of injury or illness? Surgeries: Yes No Type of Surgery Hospitalizations Yes No Reason for Hospitalization Any history of Traumatic Brain Injury (TBI) Any genetic testing done? Yes No Date of genetic testing MM slash DD slash YYYY Any hearing test done? Yes No Date of hearing test MM slash DD slash YYYY APPLICANT’S MENTAL HEALTH HISTORYDoes the applicant have any current mental health (psychiatric) diagnosis(es)? Yes No If yes, what is the applicant’s diagnosis(es)? Date of diagnosis(es)/evaluation(s)? MM slash DD slash YYYY Name(s) and address(es) of Mental Health provider(s) that the applicant is/was receiving services from:APPLICANT’S EDUCATIONAL HISTORYIs the applicant Home Schooled? Yes No If yes, then which School District? Is applicant currently or previously in a Special Education program? Yes No Does the applicant have an Individualized Education Program (IEP)? Yes No In what grade did the applicant start receiving Special Education services? Did the applicant graduate from High school? Yes No Applicant received a Diploma or Certificate of Completion Date Received MM slash DD slash YYYY Current School District: Current Grade: Primary Disability in the IEP Secondary Disability in the IEP Preschool(s): Kindergarten(s): High School(s): Middle School(s): OTHER SERVICESHas the applicant received services through the Department of Rehabilitation(DOR)? Yes No If “yes” then provide the name and address of the worker If yes, when was the case open? MM slash DD slash YYYY Has applicant received services though Child Protective Services (CPS)? Yes No If yes, when was the case open? MM slash DD slash YYYY If “Yes” then provide the name and address of the worker: Is the applicant receiving SSI benefits? Yes No Child's Social Security NumberIf “Yes”, since when? Were any services for applicant’s developmental disability received from out State of California? Yes No Which State(s)? Name and address of the agencies that provided developmental services out of California:Consent to the Assessment I agree to consentBy checking this box, I acknowledge that I am the applicant or parent of the applicant (under age 18), I hereby consent to the assessment of the individual named on this form for the purpose of determining eligibility for Regional Center services as per the Lanterman Developmental Disability Services Act. I understand that assessment may include collection and review of available historical diagnostic information, provision or procurement of necessary tests and evaluations and summarization of developmental levels and service needs. I understand that the Valley Mountain Regional Center may consider evaluations and tests, including, but not limited to, intelligence tests, adaptive functioning tests, neurological and neuropsychological tests, diagnostic tests performed by a physician, psychiatric tests, and other tests and evaluations that have been performed by, and are available from, other sources. (California Welfare and Institutions code Section 4642, 4653) I understand that all information and records obtained by the Valley Mountain Regional Center in the course of providing intake and assessment services are confidential. 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:Select the nearest Valley Mountain Regional Center office* 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 Post Excerpt After you click "Submit", print or screen shot the confirmation page that appears for your records.
