For Children 2 Years Old and Under

REGIONAL CENTER ADVOCACY ATTORNEY REFERRAL FORM FOR CHILDREN 2 ½ YEARS OLD AND UNDER** Please note: Referring a case to the Alliance for Children’s Rights does not guarantee services or representation. Please assume your case has not been accepted for assistance until you receive affirmative confirmation from the Alliance that your case has been accepted. All information is REQUIRED to investigate this referral, missing information will delay the investigation. **Age restrictions for Advocacy: the Alliance is currently only accepting cases for regional center advocacy for children between the ages of 3 months and 2 ½ years. If the child is 2 ½ or older, please consider their need for special education advocacy with the school district under a WIC 317e Referral.

Submit referral by: ☐Fax to: Data Entry @ 213-368-6016 or ☐Email to: [email protected] 1. Is this referral time-sensitive? ☐No ☐Yes, if yes, specify time frame: 2. Date of referral: Dependency Case #: 3. Minor’s Attorney Name: Phone: 4. Minor’s Attorney Email: Fax: 5. Hearing Officer: Dept: 6. Type of Hearing: Next Hearing Date: 7. County Counsel: Phone: 8. Children’s Social Worker: Phone: 9. Mother’s Attorney: Phone: 10. Father’s Attorney: Phone: 11.CASA: Phone:

12. CHILD’S INFORMATION (One child per referral form) Name: Gender: DOB: Age: Social Security #: Ethnicity: Ethnicity: 13. REFERRAL ISSUE: - Required (check all that apply and describe in detail in #14 below):

A. ☐Suspected Developmental Delay

1. ☐Cognitive 3. ☐Communic 4. ☐Adaptive 2. ☐Physical / ation Skills Motor 5. ☐Social/Emotional

B. ☐Established Risk Diagnosis (describe below): C. ☐Current IFSP is inadequate because (describe below):

14. LEGAL ISSUE /ADVOCACY NEEDED: Required (data field will expand) 15. SUPPORTING EVIDENCE: Required (check all that apply):

A. ☐Court Orders / Minute Orders B. ☐Failed developmental screening 3333 Wilshire Blvd, Suite 550 ● Los Angeles, CA 90010 ● Phone: 213-368-6010 ● Fax: 213-368-6010 Revised 4/5/2018 REGIONAL CENTER ADVOCACY ATTORNEY REFERRAL FORM FOR CHILDREN 2 ½ YEARS OLD AND UNDER** C. ☐Regional center records F. ☐MAT Report D. ☐Medical records G. ☐JV 535 for any Eductional Rights E. ☐Most recent Court Reports Holder (ERH) other than biological regarding issue parent(s) 1. 2. 3. 16. CAREGIVER INFORMATION

4. Name: 8. Legal relationship to child:

5. Address: 9. Familial relationship to child:

6. City, State, Zip: 10. Is this a Spanish speaking family?

7. Phone: 17. Is there a reason that this address needs to remain CONFIDENTIAL in all court

proceedings? If Yes, explain:

18. Please note: Prior to accepting a case for regional center advocacy, the Alliance needs your assistance in ensuring that an able and willing Education Rights Holder is identified and appointed to advocate on this child’s behalf. The Alliance is happy to work with biological parents who hold education rights as long as they are willing to actively participate in the process of seeking out services for their child. In order to work with biological parents, this form must also be completed by the parent’s attorney. Please complete the below section, in its entirety, and sign as appropriate to certify that you have identified an able and willing education rights holder. 19. 20. EDUCATION RIGHTS HOLDER(S):

21. Name: 27. Name: 22. Address: 28. Address: 23. City, State, Zip: 29. City, State, Zip:

24. Phone: 30. Phone:

25. a. Is this a Spanish speaking family? 31. a. Is this a Spanish speaking family?

26. b. ERH’s relationship to child: 32. b. ERH’s relationship to child: 33. Please complete and certify that ALL of the following below are true: A. Select type of proof of Education Rights attached:

B. ERH has a consistent method of communication: please indicate which one: If other, please explain ______C. Counsel has spoken with ERH and/or Caregiver (if different) and confirmed that they are willing to work together with the Alliance to advocate for services for the child, including but not limited to: 1. ERH/CG is willing and able to attend an In Office Intake Meeting at The Alliance

2 REGIONAL CENTER ADVOCACY ATTORNEY REFERRAL FORM FOR CHILDREN 2 ½ YEARS OLD AND UNDER** 2. ERH/CG is willing to complete a developmental screening to explore the needs of the child 3. ERH/CG is willing and able to take the child to regional center assessment appointments 4. ERH/CG is willing and able to attend Individual Family Service Planning meetings 5. ERH/CG is willing and able to access all developmental services the child is legally entitled to 34. 35. 36. ______37. Signature of minor’s counsel required Signature of parent’s counsel if bio parent is ERH

 **The Alliance’s Juvenile Court Blanket Order allows access to the case files when a Minor’s Attorney makes a referral. 38. 39.

3333 Wilshire Blvd, Suite 550 ● Los Angeles, CA 90010 ● Phone: 213-368-6010 ● Fax: 213-368-6010 Revised 4/5/2018