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916.773.1640

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Home
About Us
- Strategic Plan 2022-2025
Our Programs
Success Stories
Donate
Contact Us

Client Referral

Thank you for your interest in On My Own Community Services.

After submitting your application, we will contact you to discuss in further detail.

We look forward to meeting you!

CLIENT REFERRAL FORM

Date*
Date Format: MM slash DD slash YYYY
Client Name*
First Middle Last Suffix
Client Address*
Address 1 Address 2 City State Zip Code
Client Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number
DEPARTMENT OF REHABILITATION (DOR) REFERRAL:
Department of Rehabilitation (DOR) Counselor Name
First Last
DOR Counselor Phone
DOR Service Coordinator Name
First Last
DOR Service Coordinator Phone
HABILITATION CLIENTS ONLY:
- Check Box only if a Habilitation Client
UCI Number (Only if a habilitation client)
ACRC Service Coordinator Name
First Last
ACRC Service Coordinator Phone
Authorized Service Requested
- Job Coaching (JC)
- Job Development (JD): Intake
- Job Development (JD): Employment Preparation
- Job Development (JD): Placement
- Personal, Vocational, Social Adjustment (PVSA)
- Vocational Assessment (VA)
- Trial Work Experience (TWE)/External Situational Assessment (ESA)
- Work Experience
ALTA CALIFORNIA REGIONAL CENTER (ACRC) REFERRAL:
UCI # (Unique Client Identifier from Alta CA Regional Center):
ACRC Service Coordinator Name (Alta CA Regional Center)
ACRC Service Coordinator Phone
Authorized Service Requested
- Tailored Day Services
- Job Coaching
- Paid Internship Program
ALL REFERRALS:
Services & Supports Client Receives:*
Potential Employment Needs*
Barriers*
Additional Concerns or Information:
DOR File Upload: Please attach IPE (Individual Plan of Employment). ACRC File Upload: Please upload the most current IPP, CDER, Psychological and Social Evaluations (as applicable), as well as any additional, relevant documents.
Accepted file types: pdf.
Please attach only PDF versions of documents. All file content you attach here is secure and protected by SSL encryption over a secure HTTPS transmission. The SSL certificate is validated by the Internet Security Research Group (ISRG). All data transmission is within HIPPA and CARF guidelines.

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On My Own Community Services
1624 Santa Clara Drive #130
Roseville, CA 95661
Phone - 916.773.1640
Fax - 916.728.1005

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