Referral - Regional Center of the East Bay

Regional Center of the East Bay

Offering RCEB Families:

Service	Code	Vendor Number
Employer of Record Daycare (EOR)	EOR 062	HB0920

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)

Employer of Record Daycare (EOR)

Who will be managing the Individual Served's care?

The Individual Served

A Parent/Guardian

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

@rceb.org

Has the individual served been approved for an Exception?

Yes

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.

Regional Center of the East Bay

Referral Form

Consumer

Parent / Guardian's Information

Behavior Plan

Emergency Medications

Provider's Information

Service Coordinator

POS