[South Central Los Angeles Regional Center] Lanterman Intake Application

South Central Los Angeles

Regional Center

for Persons with Developmental Disabilities, Inc.

Lanterman Intake Application

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 determine if your address is served by SCLARC.

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 the file, then print, fill out, and return via email to LantermanIntake@sclarc.org, or by fax (213) 559-0612. To submit a referral by phone please call (213) 744-8880, or (213) 744-8872.

What's your zip code?

STOP Your zip code is not in the area serviced by SCLARC, please visit this website to find and contact the regional center that serves your area https://www.dds.ca.gov/rc/lookup-rcs-by-county/

Lanterman Intake Application

Great! Your your zip code is in the area served by SCLARC. Please review carefully the information in the next page.

Please note, your zip code is serviced by more than one Regional Center. To find out if SCLARC is your regional center please call us before completing this application at 213-744-8880, or 213-744-8872

I have called SCLARC to verify my address is in the area served by SCLARC

Great! Please review carefully the information in the next page.

Lanterman Intake Application

Please complete this application to be considered to receive Regional Center services for individuals 3 years of age and older.

For children ages 0 to 2 years and 10.5 months, please use the Early Start Intake Referral Form by clicking here https://sclarc.seamlessdocs.com/f/d6pvn2uwrjp2

This application can be filled out by a parent if child is 3-18 years old, by a conservator/legal guardian of an individual of any age, or by a non-conserved individual over the age of 18 years.

Click Next to review the Eligibility Statement and Application Instructions.

Eligibility Statement

To be eligible for Regional Center Services an individual must have a suspected or diagnosed Developmental Disability as per California Law and Regulation. A developmental disability is a condition attributable to:

Intellectual Disability
Epilepsy
Cerebral Palsy
Autism
Disabling conditions found to be closely related to intellectual disability or requiring treatment similar to.

Additionally, the disability must: Originate prior to the age of 18, continues or is expected to continue indefinitely and constitutes a substantial disability for the person. Substantial disability means significant functional limitation in three or more of the following areas of life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living, economic self-sufficiency. A developmental disability does not include other handicapping conditions that are solely physical in nature, solely psychiatric in nature and solely learning disabilities.

To determine the applicant’s eligibility, South Central Los Angeles Regional Center will complete an intake assessment which may include collection of historical diagnostic information, such as medical records, school records, prior psychological testing as well as provision of diagnostic evaluation (s) if indicated. The applicant’s information is confidential and will only be released with your written consent. Please be informed that the evaluation process cannot begin prior to receipt of your written consent. Eligibility determination may take up to 120 days.

Application Instructions

This application and screening tool will take about 30 minutes to complete. Be sure your device and internet connection are stable, as interruptions may reset the form and lose progress.
Please have supporting Medical and Educational documentation of the applicant handy, you'll be able to submit it towards the end of this application (PDF or Picture from your phone). We encourage you to submit supporting documentation along with this application in order to expedite the process, but it's not required in order to submit an application.

Please take the time to carefully review and complete accurately to the best of your knowledge every section of this application to avoid delays in processing.

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

If you are ready at this time to complete this Application and Screening tool, please check the agreement below to continue to the next page.

I HAVE REVIEWED THE ELIGIBILITY STATEMENT AND INFORMATION ABOVE AND WOULD LIKE TO APPLY FOR REGIONAL CENTER SERVICES AT THIS TIME.

Applicant Information

Ethnicity

Gender

Applicant's Preferred Language

Date of Birth

Age

Social Security Number (type NA if applicant doesn't have one)

Birth Place (Please note this does not affect eligibility)

Marital Status

Please review information before moving on to the next page.

Department of Children and Family Services (DCFS)

Is there a DCFS Children's Social Worker assigned to the applicant?

Yes

Please provide all available information.

DCFS Children's Social Worker Name

DCFS Children's Social Worker Phone Number

DCFS Worker Email

DCFS Case Number

DCFS Case Name

Please review information before moving on to the next page.

Judicial Involvement

Is there an Attorney or Public Defender representing the applicant?

Yes

Please provide all available information.

Attorney/Public Defender Name

Attorney/Public Defender Phone Number

Attorney/Public Defender Email

Case Name

Case Number

Please review information before moving on to the next page.

Educational Information

Please provide all available information.

School or Day Program Name

School or Day Program Phone Number

Teacher, Supervisor, or Counselor name

Teacher, Supervisor, or Counselor Phone Number

If applicant over 18 years: Name of the last school attended before the age of 18

Is the applicant currently, or has previously been in a special education program, or had an IEP (Individualized Education Program)? If yes, please submit a copy of your current IEP in the documents section toward the end of this application.

Yes

Please review information before moving on to the next page.

Medical Information

Does the applicant have any medical diagnoses or chronic health conditions?

Yes

Medical History

Physician Name

Please list any medications that the applicant is currently taking for his/her medical condition.

Does the applicant have a current mental health (psychiatric) diagnosis?

Yes

Mental Health History

Mental Health Provider Name

Please list any medications that the applicant is currently taking for his/her mental health (psychiatric) condition:

Does the applicant have health insurance?

Medi-Cal

Private Insurance

No Insurance

Please review information before moving on to the next page.

Reason for Applying

If available, upload a copy of the applicant's insurance in the documents section toward the end of this application.

Please indicate the developmental disability that is suspected or diagnosed for the applicant. You may indicate more than one area of developmental disability. SCLARC will perform assessment to determine if the applicant meets the definition of developmental disability per California Law and Regulation.

Intellectual Disability

Autism Spectrum Disorder

Cerebral Palsy

Epilepsy

Conditions Similar to Intellectual Disability

Briefly describe below the applicant’s deficits, behaviors and/or concerns:

Referred by:

Referrer Name

Referrer Phone Number

Has the applicant previously received assessment or services from a Regional Center?

Yes

What regional center?

SCLARC

Other Regional Center

Regional Center Name

UCI Number

Please review information before moving on to the next page.

By submitting this application I certify all information is true and correct to the best of my knowledge. If completing on behalf of another person, I certify I am authorized to represent that individual.

I have read and agree with the statement above.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

South Central Los Angeles Regional Center

Lanterman Intake Application

Lanterman Intake Application

Applicant Information

Primary Responsible Party Information

Department of Children and Family Services (DCFS)

Judicial Involvement

Educational Information

Medical Information

Reason for Applying

Documents