ICC Add Contact

Please fill out to get to know the client and determine whether a full assessment meeting is appropriate

Check if Contact is already in the system.

Click on Add below to search. If Contact or Client is listed STOP and go to another form. They are already in the CRM.

Add

Contact Name

Client/Child's Name

If client's name is missing from the database, please fill out add Client form first to add the client. https://airtable.com/shrEGNBeBGfndOxlk

Add

Child's/Client's Date of Birth

Relationship to Client

Address

Zip Code

Integradora's Name

Add

Email Address

Parent Language(s)

Select all that apply

Ethnicity

Select all that apply

Client Language

Select all that apply

# of people living in household

Have you ever been evaluated by Regional Center?

Regional Center

Verbal/Non Verbal?

Select all that apply

Diagnosis

Concerns

Mobile

Can you receive text messages?

Best time to contact

Alternate phone number

Coordinator

Did you submit in the Self Determination lottery?

Are you in Self Determination?

Would you like to be trained on Self Determination?

Would you like to become an independent facilitator trained by ICC?

Would you like to be trained on Person Centered planning?

Are you or another family member interested in any of the following programs?

Select all that apply

Have you or any of your family members been diagosed with covid-19?

Check all that apply.

School Name