List of Records Regional Centers May Ask for
When You Apply for Services

The regional center may ask you for the information listed below. If you copy this form and fill it out, it will help you to be ready when you apply for services.

If you have any questions about these records, call OCRA or PAI.

About You

Name:

Address:

street city state zip code

Phone number:

Parent or Guardian’s name:

Your Medical Records

List each doctor, psychologist or other health care provider who has cared for you:

1. Doctor’s name: Phone #:

Address:

street city state zip code

2. Doctor’s name: Phone #:

Address:

street city state zip code

3. Doctor’s name: Phone #:

Address:

street city state zip code

4. Doctor’s name: Phone #:

Address:

street city state zip code

5. Doctor’s name: Phone #:

Address:

street city state zip code

6. Doctor’s name: Phone #:

Address:

street city state zip code

Hospitals and Clinics

List each hospital or clinic where you received care, including where you were born:

1. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

2. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

3. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

4. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

5. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

6. Name of Hospital or Clinic: Phone #:

Address:

street city state zip code

Medications

Many consumers take lots of medication. List all medications you have taken:

Medications you take now:

Early Start/Head Start Records

Program name: Phone #:

Address:

street city state zip code

Other program name (if any): Phone #:

Address:

street city state zip code

School Records

List each school you have attended:

1. Name of School Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code

2. Name of School: Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code

3. Name of School: Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code

4. Name of School: Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code

5. Name of School: Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code

6. Name of School: Phone #:

(Check one): q Preschool q Elementary School q Middle school q Other

Address:

street city state zip code