Buellton

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Carpinteria

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Guadelupe

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Isla Vista

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Goleta

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

La Conchita

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Lompoc

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Los Alamos

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Los Olivos

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Montecito

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

New Cuyama

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Orcutt

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Santa Barbara

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Santa Maria

(22) TCRC Web Intake Form - Santa Barbara North Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Solvang

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Summerland

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Vandenburg

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)

Toro Canyon

(23) TCRC Web Intake Form -Santa Barbara South Over 3yo

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:

  1. self-care
  2. receptive and expressive language
  3. learning
  4. mobility
  5. self-direction
  6. capacity for independent living
  7. 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)
MM slash DD slash YYYY
Gender(Required)
Is applicant known to school - (Select all that apply)(Required)
Parent / Guardian Name(Required)
Mailing Address(Required)
Check if your phone is a mobile phone
Suspected Disability - (Select all that apply)(Required)