Follow the steps to complete your online application.

1. Press the ‘Get Form’ button to obtain the required application form and open it in the online editor.
2. Begin by entering the applicant's name, including last name, first name, and middle initial, in the designated fields.
3. Fill in the date of birth using the MM/DD/YY format in the appropriate field.
4. Indicate the applicant's gender by selecting either 'Male' or 'Female.'
5. Enter the Social Security Number (SSN) of the applicant in the provided field.
6. Select the ethnic background from the available options, ensuring to check any relevant categories.
7. Indicate the primary language spoken by the applicant using the dropdown options provided.
8. In the insurance section, check all applicable coverage types, and provide plan names where necessary.
9. Complete the parent or legal guardian's details, including name, relationship to the applicant, and primary contact information.
10. Fill out the alternate contact information, specifying the relationship to the prospective client and their preferred contact number.
11. Provide a brief outline of concerns and reasons for referral in the designated text area.
12. Mark the eligible conditions that apply to the applicant by selecting from the list provided.
13. If applicable, state whether the applicant is five years old or younger and specify any documents that are still pending.
14. Finally, review your entries for accuracy and completeness, and then save the changes. You can choose to download, print, or share the completed form as needed.

Complete your Westside Regional Center Intake Application Form online today.