APPENDIX E

Checklist for Applying for
Regional Center Services

Some of the records that the regional center may request during the application process may not support your application for regional center services.

Personal Information:

·       Name, Address, Telephone Number of Parent(s) or Guardian.

Medical Information:

·       Names, Addresses, and Telephone Numbers of Doctors, Psychologists or other Health Care Professionals:

Dr.: Address: City: State: Zip: Telephone: (   )

·       Hospitals and Clinics (Including Birth Records):

Name: Address: City: State: Zip: Telephone: (   ) Date(s) of Admission

·       Medications

·       Current Medications

Early Start/ Head Start Records

 

 

 

Education Records

·       School Records:

School Name: Address: City: State: Zip: Telephone: (   )

 

If you have any questions about the records contained in this checklist, you may contact OCRA or PAI for consultation.