Connect with an Intake Coordinator in SLO Connect with Intake Coordinator - SLO County - Over 3 (Web_Intake_03_SLO) Eligibility Application TCRC Eligibility Requirements: An application must be completed in order to assist Tri-Counties Regional Center (TCRC) to determine eligibility for services under the Lanterman Developmental Disabilities Services Act. To be eligible for Regional Center Services, an individual must have a Developmental Disability per California Welfare and Institutions Code, Section 4512. “Developmental disability” means a disability that originates before an individual attains 18 years of age; continues, or can be expected to continue, indefinitely; and constitutes a “substantial disability” for that individual. Developmental disabilities include: Intellectual Disability Autism Spectrum Disorder Cerebral Palsy Epilepsy Disabling conditions found to be closely related to Intellectual Disability or requiring treatment similar to that required for individuals with an Intellectual Disability but shall not include other handicapping conditions that are solely physical in nature. “Substantial disability” means the existence of significant functional limitations in three or more of the following areas of life activity, as determined by a regional center, and as appropriate to the age of the person: self-care receptive and expressive language learning mobility self-direction capacity for independent living economic self-sufficiency To determine the applicant’s eligibility, TCRC 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 if indicated. The evaluation process cannot begin prior to receipt of your written consent. The evaluation and eligibility determination will be completed in a timely manner but within a maximum of 120 days of the initial intake inquiry. The applicant’s information is confidential and will only be released with your written consent. Please complete the following information completely. Applicant Name - (if you are the parent, enter the child's name)(Required) First Last DOB - (enter child's Date Of Birth)(Required) MM slash DD slash YYYY Gender(Required) Male Female Is applicant known to school - (Select all that apply)(Required) Schools - IEP, 504 Plan CSS - County Social Services (CWS or APS) BH - Behavioral Health MH - Mental Health CCS - California Children's Services DOR - Department of Rehabilitation Other Regional Center None of the above Parent / Guardian Name(Required) First Last Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Language(Required) Contact Email(Required) Contact Phone Number(Required)Check if your phone is a mobile phone Mobile Phone (Accepts SMS Texts) Suspected Disability - (Select all that apply)(Required) Intellectual Disability Epilepsy Cerebral Palsy Autism Other Significant Delay Detailed Reason for referral / inquiry for suspected disabilities(Required)