Apply For Services

I hereby authorize Harbor Regional Center to perform medical, psychological, developmental, and any other diagnostic assessments/evaluations needed to establish whether the person named in this application is eligible for service as a client of Harbor Regional Center. I understand that such diagnostic assessments/evaluations may be performed by Regional Center staff, or by specialists in the community paid by private insurance or public funds other than Regional Center’s or by state-approved clinicians from whom Harbor Regional Center may purchase services.

I understand that as part of the assessment to establish eligibility for services, a staff person from Harbor Regional Center and/or a clinician chosen by Harbor Regional Center may conduct observations of the individual in home and community settings. Furthermore, I will be informed of the date and times of such observations, should they be necessary. I consent to observations of the individual in home and community settings. Furthermore, I will be informed of the date and times of such observations, should they be necessary. I consent to observations by Harbor Regional Center staff of a clinician designated by Harbor Regional Center.

I have read and understood the above statements and agree to each item. I understand that by entering my name below, I consider this my electronic signature for this authorization and submittal.