Tri-Counties Regional Center - Intake Form
This form is designed to gather essential information about your child and family to help us provide the best possible services. Please fill out the required details so we can better understand your needs and ensure a smooth enrollment process.
If this information is not applicable or you don’t have it, please feel free to enter ‘N/A.’
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Parent's Full Name *
Parent's Phone Number *
Parent's Email  *
Service Coordinator's Full Name *
Service Coordinator's Phone *
Service Coordinator's Email  *
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