Interest Questionnaire

If applicable, please list any previous medical diagnosis your child has had:

When did these assessments take place?

List any medication your child is currently taking

Has your child had a hearing test?

If so, when?

Does your child have a history of ear infections?

If so, how often?

Please select all of the programs your child is currently receiving or has received:

IEP - Individualized Education Plan - The Individualized Education Program is a legal document under United States law that is developed for each public school child in the U.S. who needs special education.IFSP - Individual Family Service Plan through Regional Center -this is a family-focused plan for providing early intervention services to infants and toddlers.504 Plan - a plan developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives accommodations that will ensure their academic success and access to the learning environment.IHSS - The In-Home Supportive Services program provides in-home assistance to eligible aged, blind and disabled individuals as an alternative to out-of-home care and enables recipients to remain safely in their own homes.SSI - Supplemental Security Income is designed to help aged, blind, and disabled people, who have little or no income and provides cash to meet basic needs for food, clothing, and shelter.CCS - California Children’s Services (CCS) is a statewide program that arranges, directs, and pays for medical care, equipment, and rehabilitation, when these services are authorized for children and young adults under 21 years of age who have eligible medical conditions and whose families are unable to pay for all or part of their care.DOR - The California Department of Rehabilitation (DOR) can supply you with a wide variety of counseling, training, job skills, and job placement services. DOR can help you get the training or other services that you need to return to work, to enter a new line of work, or to enter the workforce for the first time.

Please list dates of the most recent report and/or any additional details regarding these services (i.e., Most recent IEP was in Oct 2021')

Regional Center - Regional centers provide assessments, determine eligibility for services, and offer case management services

Check here if your child is receiving or has received services from Regional Center.

Who is or was the Regional Center case worker?

Did your child receive a diagnosis from Regional Center? If so, what was the diagnosis?

If you no longer receive services through Regional Center, what was the exit date?

Date

Regional Center Appeal

Check here if you are appealing a Regional Center assessment

If so, when did the assessment take place?

Date

Where did the assessment take place?

Please provide details for all services marked above:

Please describe your main concerns and/or behavior patterns for which you wish to have your child assessed.

Interest Questionnaire

Previous Medical History

Therapy Services

Insurance Information

Primary Insurance

Secondary Insurance