South Central Los Angeles
Regional Center

For Persons with Developmental Disabilities, Inc
213-744-7000

SCLARC Lanterman Intake Application

SCLARC provides services within the Los Angeles County health districts of South Los Angeles, Watts, Leimert Park, Florence/Firestone, West Adams, and the cities of Bell, Bell Gardens, Compton, Cudahy, Downey, Huntington Park, Lynwood, Maywood, Vernon, South Gate, North Carson, Gardena, and Paramount.

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 this website to find and contact the regional center that serves your area. https:/www.dds.ca.gov/rc/lookup-rcs-by-county/

What's your zip code? *

Please select an option

*Zip code shared with another Regional Center. Depending on where you live, your referral may be forwarded to the Regional Center that serves your area.

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

Please check the box

Lanterman Eligibility Criteria

Children and adults (three years of age and older) may be eligible to receive regional center services if they have a developmental disability according to California Law and Regulation.

To be eligible for Regional Center services, an individual must have a substantial disability 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, and continues, or is expected to continue indefinitely, and constitutes a substantial disability for the person. A substantial disability means that the person has a significant functional limitation in three or more of the following areas of life activity:

1. Self-care
2. Receptive and expressive language
3. Learning
4. Mobility
5. Self-direction
6. Capacity for independent living
7. Economic self-sufficiency.

A developmental disability does not include other handicapping conditions that are solely physical or psychiatric in nature, or solely learning disabilities.

To determine the applicant’s eligibility, SCLARC 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 diagnostic evaluation if available. The applicant's information is confidential and will only be released with written consent. Please be informed that the evaluation process cannot begin prior to receipt of written consent. Eligibility determination may take up to 120 days.

For more information on Lanterman Act Eligibility Criteria, visit Lanterman Act Eligibility Criteria

Provisional Eligibility for Children Ages 3 – 4

If a child who is three or four years of age is not otherwise eligible for regional center services as a result of a developmental disability as speciﬁed in W&I Code section 4512(a)(1), the child shall be provisionally eligible for regional center services if the child has a disability that is not solely physical in nature and has signiﬁcant functional limitations in at least two of the following areas of major life activity, as determined by a regional center and as appropriate to the age of the child:

1. Self-care
2. Receptive and expressive language
3. Learning
4. Mobility
5. Self-direction

For more information on the State Department of Developmental Services (DDS) Directive on Provisional Eligibility, visit Provisional Eligibility for Regional Center Services

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

Please check the box

Name of Person in Need of Regional Center Services

First Name *	Initial	Last Name *

Please input		Please input

If the applicant's name has been changed, please list former full name. Otherwise, leave blank and continue below.

First Name	Initial	Last Name

Ethnicity *	Gender *	Applicant's Preferred Language

Please select an option	Please select an option
Social Security Number (type NA if applicant doesn't have one)	Birth Place (City, State / Country) (Please note this does not affect eligibility)	Marital Status

		Please select an option

Please review information before moving on to the next page.

Primary Responsible Party Information

Who is completing this online referral application?*

Self/lndependent	Parent
Professional	Legal Guardian / Other
Please select an option

Agency Name *

Please input
Agency Type *
School	Pediatrician/Doctor
Other Medical Professional	Preschool/Head Start
Mental Health Provider	Family Resource Center
Attorney/Public Defender	Other
Please select an option
Name of Person Making Referral

Phone Number
( ) -
Email

Who is completing this online referral application?*

Legal Guardian	Foster Parent
Residential Care Facility	Adoptive Parent
Please select an option

Your Name

First Name *	Initial	Last Name *

Please input		Please input
Responsible Party's Preferred Language*

Please input

Your Address

Street Address*

Please input

City *

State *

Zip *

Please input

Primary Phone Number*

( ) -
Please input Please input Please input Please input
Type of Primary Phone*
Cellphone	Landline
Work	Other
Please select an option

By checking this box, you consent to receive text messages from South Central Los Angeles Regional Center regarding your services. In accordance to our Privacy Policy you may opt-out at any time by replying STOP. For assistance, text HELP. Message and data rates apply. Messaging frequency may vary.

Secondary Phone Number

( ) -
Type of Secondary Phone
Cellphone	Landline
Work	Other

Email: Please include an email address to be contacted via email

Please enter correct email address

Does applicant currently reside at same address as responsible party? *
Yes	No
Please select an option

Applicant's Current Address

Street Address*

Please input

City *	State *	Zip *

Please input	Please input	Please input
Primary Phone Number*
( ) -
Please input
Type of Primary Phone*
Cellphone	Landline
Work	Other
Please select an option
Secondary Phone Number
( ) -
Type of Secondary Phone
Cellphone	Landline
Work	Other

Biological Parent Full Name (if known)

First Name	Initial	Last Name

Biological Parents Current Address (if known)

Street Address


City	State	Zip

Biological Parent Phone Number (if known)
( ) -
Type of Phone for Biological Parent (if known)
Cellphone	Landline
Work	Other

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	No
Please select an option

Please provide all available information

DCFS Children's Social Worker Name

DCFS Children's Social Worker Phone Number ( ) -

DCFS Worker Email

Please enter correct Email address

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	No
Please select an option

Please provide all available information

Attorney/Public Defender Name

Attorney/Public Defender Phone Number ( ) -

Attorney/Public Defender Email

Please enter correct Email address

Case Name

Case Number

Please review information before moving on to the next page.

Educational Information

We encourage you to provide this information in order to expedite the process, but it's not required in order to submit an application.

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)?
Yes	No

Please review information before moving on to the next page.

Medical Information

Does the applicant have any medical diagnoses or chronic health conditions?*
Yes	No
Please select an option

Medical History *

Please input

Physician Name

Please input

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

Please input

Does the applicant have a current mental health (psychiatric) diagnosis?*
Yes	No
Please select an option

Mental Health History *

Please input

Mental Health Provider Name

Please input

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

Please input

Does the applicant have health insurance?*
Medi-Cal (Please enter Medi-Cal BIC number, if known)

Private Insurance
No Insurance
Other
Please check

Please review information before moving on to the next page.

Reason for Applying

Please check the box(es) for the developmental disability suspected or diagnosed for the applicant. You may indicate more than one area of developmental disability. SCLARC will contact you to schedule an assessment to determine if the applicant is eligible, per California law and Regulation. *
Intellectual Disability	Autism Spectrum Disorder
Cerebral Palsy	Epilepsy/Seizure Disorder
Conditions Similar to Intellectual Disability
Please check

Briefly describe below the applicant’s developmental delays, behaviors and/or concerns: *

Please input

After completing the submission, you can upload documents related to applicant's development/medical condition(s).

Please review information before moving on to the next page.

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

Yes	No
Please check

UCI Number(Unique Client Identifier - this number is not required)

What regional center? *

SCLARC
Other Regional Center
Please check

Please input

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.


I have read and agree with the statement above.
Please check the box
Sign Here *
First Name	Last Name

Please input	Please input
Email

Please enter correct email address


Please Sign

Thank you!

We have received your referral for

If you have any documents to upload which provide information related to your child’s development/ medical condition(s), please use this link to upload them.

UPLOAD DOCUMENTS

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We have received your referral, and will contact you within the next 15 business days, at the email address or phone number you provided. If you are a professional submitting a referral on behalf of someone else, SCLARC will contact the parent or guardian listed in the application. If no contact is made after 15 business days, please call SCLARC staff at (213) 744-8800, or email us at lantermanintake@sclarc.org. Due to the large number of referrals received, please give us 15 business days before following up with your application.

What happens after a referral is made to SCLARC Lanterman Intake?