• 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.
  • Format: (000) 000-0000.
  • What is your child’s date of birth?
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  • Does your child have a diagnosis?
  • Does your child have any of the following diagnoses?
  • Do you or your child’s doctor have concerns in any of the following areas of development?

  • Regional Center

  • Is your child a Regional Center client?*
  • Is your child currently enrolled in the Self-Determination Program?
  • What services do you currently receive from Regional Center? Select all that apply.
  • What services do you not currently receive but would like to seek from Regional Center or learn more about? Select all that apply.
  • Would you like help from Undivided in applying for Regional Center and/or accessing more services?*

  • Insurance and Medi-Cal

  • Does your child currently have Medi-Cal?*
  • How are you currently using Medi-Cal?
  • Has your private insurance denied any of the following?
  • Would you like help from Undivided in applying for Medi-Cal and/or accessing the full benefits your child is eligible for?*

  • In-Home Supportive Services (IHSS) and California Children's Services (CCS)

  • Do you receive In-Home Supportive Services (IHSS)?
  • Who is the IHSS caretaker for your child?
  • Would you like help from Undivided in applying for IHSS and/or maximizing your hours?*
  • Does your child receive services from California Children’s Services (CCS)?

  • Specialists and Therapies

  • What barriers are in the way of accessing the specialists/therapies your child needs? Select all that apply.

  • Education

  • What school age is your child?
  • Does your child have an Individualized Education Program (IEP) or 504 plan in place?*
  • Which best describes your child’s current placement?
  • What concerns do you have about your child’s experience at school? Select all that apply.
  • How well do you work with the school team?
  • Does your child’s IEP/504 state if they are on a diploma or certificate track?
  • Does your child qualify for the CAASP state assessments or the alternate assessments (CAA)?
  • Would you like help from Undivided in making sure the right supports are in place at your child’s school?*

  • How can Undivided help?

  • When it comes to raising your child, where would you like the most support?
  • What best describes your Internet use?
  • Should be Empty: