Language
English (US)
General information
Take a minute to tell us more about you, your child, and the services your family receives so that we can help you identify what priorities to work on.
Full name
*
First Name
Last Name
Email
*
Zip code
*
Phone number
Please enter a valid phone number.
What is your child’s date of birth?
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Month
-
Day
Year
Date
Does your child have a diagnosis?
Yes (I have a diagnosis)
No (I or my child’s doctor have developmental concerns)
Both (I have a diagnosis and have concerns about additional areas of development)
Diagnosis Rollup
Does your child have any of the following diagnoses?
Cerebral palsy
Epilepsy
Autism
Intellectual disability
Condition closely related to intellectual disability or requiring similar supports
Other
Do you or your child’s doctor have concerns in any of the following areas of development?
Social: emotions, interacting with others
Adaptive: daily activities such as dressing
Physical: large and small movements
Communication: pre-speech and language
Cognitive: thinking and problem-solving
Form ID
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Regional Center
Is your child a Regional Center client?
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Yes: currently receiving services
Currently in the process of applying
No, my child is not eligible for Regional Center services
No, I’m not sure if my child is eligible for Regional Center services
Select your current Regional Center
Is your child currently enrolled in the Self-Determination Program?
Yes
No
Currently in the process of applying
What services do you currently receive from Regional Center? Select all that apply.
Early intervention therapies
Respite hours
Specialized supervision or daycare
Behavioral therapy services
Copayment assistance
Social-recreational program funding
Social skills classes
Funding for durable medical equipment, accessibility modifications, or medical supplies
Educational support
Other
What services do you not currently receive but would like to seek from Regional Center or learn more about? Select all that apply.
Early intervention therapies
Respite hours
Specialized supervision or daycare
Behavioral therapy services
Copayment assistance
Social-recreational program funding
Social skills classes
Funding for durable medical equipment, accessibility modifications, or medical supplies
Educational support
Other
Would you like help from Undivided in applying for Regional Center and/or accessing more services?
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Yes
No
I’m not sure yet
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Insurance and Medi-Cal
What is your primary insurance provider?
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What is your annual out-of-pocket cost (approximate)?
Does your child currently have Medi-Cal?
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Yes
Yes, through the Medi-Cal waiver program
No
How are you currently using Medi-Cal?
Primary insurance
Secondary insurance (e.g., copays not covered by private insurance)
Other
Has your private insurance denied any of the following?
Therapies
Durable medical equipment
Skilled nursing (G-tube, trach, etc.)
Incontinence supplies (after age 3)
Other
Approximately how many out-of-network claims do you submit to private insurance per month?
Would you like help from Undivided in applying for Medi-Cal and/or accessing the full benefits your child is eligible for?
*
Yes
No
I’m not sure yet
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In-Home Supportive Services (IHSS) and California Children's Services (CCS)
Do you receive In-Home Supportive Services (IHSS)?
Yes
Currently in the process of applying
No
How many IHSS hours do you receive per month?
Who is the IHSS caretaker for your child?
I am the only caretaker
We have one non-family member caretaker
We have multiple non-family caretakers
Other
Would you like help from Undivided in applying for IHSS and/or maximizing your hours?
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Yes
No
I’m not sure yet
I would like to understand whether my child qualifies for IHSS
Does your child receive services from California Children’s Services (CCS)?
Yes
No, my child is not eligible
No, I’m not sure if my child is eligible
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Specialists and Therapies
What specialists/therapies does your child currently access?
What specialists/therapies do you wish your child could access?
What barriers are in the way of accessing the specialists/therapies your child needs? Select all that apply.
Not sure how to find the right providers
Insurance doesn’t cover it
Out-of-pocket costs are not affordable
Waitlist is long
Other
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Education
What school age is your child?
Preschool
Elementary school
Middle school
High school
My child hasn’t started school yet
What grade is your child currently in?
Does your child have an Individualized Education Program (IEP) or 504 plan in place?
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Yes
No
Currently in the process of evaluation for special education services or their first IEP/504
Which best describes your child’s current placement?
General education classroom
Specialized Day Class or Specialized Academic Instruction
Non-public school or private school
Homeschool or independent study
What concerns do you have about your child’s experience at school? Select all that apply.
Goals
Type of placement
Level of inclusion/socialization with peers
Accommodations/modifications
Adaptive equipment such as AAC
Behavioral services and/or aide
Other
How well do you work with the school team?
We work very well together, and I feel my concerns are almost always addressed.
I regularly have conflicts with my team and find it hard to work together.
I don’t know my team well or at all.
Other
Does your child’s IEP/504 state if they are on a diploma or certificate track?
Yes
No
I’m not sure
Does your child qualify for the CAASP state assessments or the alternate assessments (CAA)?
Yes
No
I’m not sure
My child hasn’t started state testing yet
Would you like help from Undivided in making sure the right supports are in place at your child’s school?
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Yes
No
I’m not sure yet
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How can Undivided help?
When it comes to raising your child, where would you like the most support?
Education
Funding options
Medi-Cal
Regional Center
IHSS
Insurance
Other
Do you have any questions about Undivided and the services we offer?
What best describes your Internet use?
I do everything on my phone, and not much from a desktop or laptop
I use my computer for most online activity
I’m evenly split, depending on the activity and time of day
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