Ventura County Intake - Age 3 and Over - Tri Counties Regional Center

Click on the city nearest to the person seeking services…

Bell Canyon

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Camarillo

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Casitas Springs

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

El Rio

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Faria Beach

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Fillmore

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Lake Sherwood

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Meiners Oaks

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Mira Monte

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

La Conchita

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Moorpark

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Newbury Park

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Oak Park

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Oak View

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Ojai Valley

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Oxnard

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Piru

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Point Mugu

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Port Hueneme

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Santa Paula

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Santa Rosa Valley

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Saticoy

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Simi Valley

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Somis

TCRC Web Intake Form - Fillmore Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services

If you are a parent or guardian, enter the age of the child.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Thousand Oaks

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Ventura

TCRC Web Intake Form - Oxnard Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments

Westlake Village

TCRC Web Intake Form - Simi Valley Area Over 3yo

Name of Person Applying for Services(Required)

Birthday of Person Applying for Services(Required)

If you are a parent or guardian, enter the birthday of the child.

Age of the Person Applying for Services(Required)

Please enter a number from 3 to 150.

City in Which Person Applying Lives(Required)

Parent or Guardian Name

Preferred Language

Email of the Contact Person(Required)

Telephone of the Contact Person

Best Way to Contact

Issues / Comments