LAJAC Intake Form

I am a *This question is required.

• Caregiver
• Adult looking for services
• Professional seeking resources

My age range is

• 18 - 22
• 23 - 30
• 31 - 40
• 41 - 50
• 50+

Are you a current client of Regional Center? *This question is required.

• Yes
• No

I am interested in learning more about the following (check as many as apply)

• Day Programs and Work Options
• Housing and Independent Living Options
• Mental Health Services
• Transportation
• Government Benefits
• Legal and Financial
• Social Opportunities