[South Central Los Angeles Regional Center] Early Start Intake Referral Form

SCLARC South Central Los Angeles

Regional Center

for Persons with Developmental Disabilities, Inc.

Early Start Intake Unit Referral Form

Hello, SCLARC provides services within the Los Angeles County health districts of Compton, San Antonio, South, Southeast, and Southwest LA.

Continue below and select your zip code to begin the online application.

If you do not see your zip code listed, your zip code is not served by SCLARC. Please visit https://www.dds.ca.gov/rc/lookup-rcs-by-county/ to find out which Regional Center serves your area.

This online form is the fastest and most convenient way to apply for services at SCLARC. Alternatively, applications and referrals can be submitted by email, fax, or phone. To submit this application via email or fax instead, click here to download, then print, fill out, and return via email to earlystartintake@sclarc.org or via fax at (213) 947-4115. To submit a referral by phone please call (213) 744-7068, or (213) 744-8807, or (213) 744-8809.

By completing this form you agree to be contacted by phone call, text, and/or email by a Regional Center representative during business hours.

What's your zip code?

Please complete this referral form to be considered to receive Regional Center services for children 0 to 2 years and 10.5 months of age only.

For individuals over 3 years of age please use the Lanterman Intake Application by clicking here https://sclarc.seamlessdocs.com/f/rjm9tlx0m6ae

As of today, how old is the child?

Years

Months

Child's Information

Date of Birth

Ethnicity

Gender

Social Security Number (Type in NA if the child doesn't have one. This will not affect eligibility or services provided by the Regional Center)

Language

Name of person/agency making referral and phone number

Information of adult responsible for child

Are you (the person filling out this application) the child's primary caregiver?

Yes

I'm not the caregiver, or I'm completing this referral on behalf of the primary caregiver.

Your Email

Caregiver's Email

Caregiver's Relationship to child

Primary Phone Number

Primary phone type

Cellphone

Landline

Secondary Phone Number

Secondary phone type

Cellphone

Landline

Preferred Language

Is there a DCFS Case (Department of Children and Family Services) or Worker assigned to the applicant?

Yes

Please provide all available information.

DCFS Social Worker Name

DCFS Social Worker Phone Number

DCFS Social Worker Email

Reason for Applying

Has the child previously applied for or received services from South Central Los Angeles Regional Center or another Regional Center?

Yes

What regional center?

SCLARC

Other Regional Center

Regional Center Name

UCI Number

In the box below, please describe your concerns regarding the childâs development and any medical conditions

Documents

Please select below documents to attach and submit with this referral. Documents may be in format PDF, DOCX, or JPG(picture). Note, medical records and other documents may be necessary to process this referral, referrals without documents attached may be delayed. If no documents are to be submitted at this time, click Next to continue to next page to sign and submit this application.

Medical Records