Apply For Services

Step 1 of 2

Thank you for your interest in applying for services at Harbor Regional Center. You do not live in Harbor’s service area. Click below to find your local regional center.

Regional Center Lookup

What is Your Residential Zip Code?*

Applicant's Biographical Information

Full Legal Name*

First

Preferred Name/Additional Names Used

First

Primary Language*

Other (Primary Language)*

Race and Ethnicity*

Two or More/Other (Ethnicity)*

If Two or More or Other was selected, please specify.

Birthdate*

MM slash DD slash YYYY

Gender

Primary Phone Number*

Address*

Street Address City State ZIP Code

Does the applicant have health insurance?*

Yes

Private Insurance

Name of Insurance and ID Number

Medi-Cal

Name of Provider and ID Number

Parent/Legal Guardian Information The parent/legal guardian fields are only required if the birthdate is 2006 and later. e.g. 2006 to now.

Full Legal Name of Parent/Legal Guardian

First

Phone

Social Security Number?*

Please provide the 9-digit social security number for the individual applying for services.

Yes

Do not wish to disclose.

Social Security Number*

Please provide Social Security Number for individual seeking services.

0 of 9 max characters

Additional Information

Have you received prior regional center services?

Yes

Regional Center

Do you have siblings or a parent who has received services at Harbor Regional Center?

Yes

Name

Relationship

Have you had any special education from the school district?

Yes

Name of School/District

Are you currently receiving mental health services?

Yes

Name of Organization/Therapist

How did you hear about us?

Person Completing Request

Please note that all regional center services are voluntary, and require the permission of the legally responsible parent, guardian, or conservator before we can proceed with an assessment.

Are you the parent or legal guardian/conservator?*

Yes

What is your relationship?*

Other*

Your Email*

Questionnaire

Early Start

Was the pregnancy full term?

Yes

How long?

What areas are there concerns with the child’s development? (Select all that apply)

Select all that apply.

Vision

Hearing

Cognitive (How a child learns new things and solves problems, it may include how children explore their environment to figure things out)

Physical/Motor development (How a child use their bodies, such as taking a few steps on their own, catching a ball, eating with a spoon)

Communication (How children understand what is said to them, how children express their needs and share what they are thinking)

Social/Emotional (How children interact with others and show emotion)

Adaptive (How a child engages in everyday living skills like eating, dressing, caring for self)

Do you believe that the child has or is at risk of any of the following conditions?

Select all that apply.

Vision

Hearing

Chromosomal and genetic disorders

Congenital malformations

Neurological disease or trauma

Poisoning or toxic exposure with neurological sequelae

Prematurity < 32 weeks

Neonatal seizures

Assisted ventilation for > 48 hours

Other

Lanterman

Do you have any concerns in the following areas?

Select all that apply.

Intellectual Disability

Autism Spectrum Disorder

Epilepsy

Cerebral Palsy

Down Syndrome

Condition similar to intellectual disability

Other

Upload Supporting Documents

Please upload any supporting documents, if available, that you feel will assist us in evaluation, such as medical, psychological, school, or other assessment reports.

Drop files here or

Max. file size: 100 MB.

Acknowlegement*

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.

I agree to the terms stated above.

Full Name*

First

Relationship to Applicant*

Self

Parent

Conservator

CAPTCHA

This field is hidden when viewing the form

Form Routing*

Lanterman

Early Start

Application for Services

Applicant's Biographical Information

Additional Information

Person Completing Request

Questionnaire

Early Start

Lanterman