Referral - Alta California Regional Center

Alta California Regional Center

Offering ACRC Families:

Service	Code	Vendor Number
Full Service Agency Respite	AR 862	HA0589
Employer of Record Respite (EOR)	EOR 862	HA0589

Fill out the following information and submit it electronically.

Once we receive the referral, our office will contact the family by sending out an application packet (EOR) or conducting an intake to assess the family's needs. (Full Service AR)

Full Service Agency Respite

Employer of Record Respite (EOR)

Who will be managing the Individual Served's care?

The Individual Served

A Parent/Guardian

PHS will process up to two EOR Care Providers per family at no cost to the referred family. A $75 processing fee will apply for each additional EOR Care Provider requested within the same calendar year.

Please ensure that a separate referral is completed for each individual served

Parent / Guardian's Information

Behavior Plan

Please upload the Individual Served's IPP. If you are submitting a referral for Personal Assistence (PA), an IPP is required.

Choose file

Provider's Information

First Name

Last Name

Service Coordinator

First Name

Last Name

Phone

@altaregional.org

POS

Total # of Hours

Per

Day

Month

Quarter

Year

Total

Additional Instructions

Before Leaving This Page

Wait until you see the "Thank You" message. Do not leave this page before that. Once your referral is successfully submitted, you will receive an emailed receipt.

Alta California Regional Center

Referral Form

Consumer

Parent / Guardian's Information

Behavior Plan

Emergency Medications

Provider's Information

Service Coordinator

POS