Step 1: WAITLIST for Sunny Coast Preparatory and Day Programs - Le Blanc Consulting

Sunny Coast
Prep and Day Programs

WAIT-LIST

STEP 1) Fill out the basic information request below, upload Clients educational and/or psychological evaluations for our review. If you do not have these we would appreciate being able to review previous educational plans (IEP’s).

STEP 2) Fill out the Application

STEP 3) Pay the non-refundable $75 Application fee

STEP 4) Schedule an appointment for intake and assessment interview with our staff

Step 1: WAIT-LIST
(To be done before application)

* Indicates required field

New Client Basic Information

Service Type *

Case manager or caller provides the following information about the client

If you are at the computer, can you please send me over your clients file or any information that you have on him or her so I can add it to our computer system? *

Client UCI or Case Number *

Prospective Client Name *

First

Last

Gender *

DOB: (IE: 01-13-1976) *

Clients Age *

Clients Parents Name (if under 18 or Conserved) or 1st Child's Name *

First

Last

Clients Parents Phone Number *

Name *

First

Last

Did you contact the client? *

Client Phone Number *

Home Phone or 2nd Number *

Address *

City *

Zip *

Upload Clients Regional Center File or information *

Max file size: 20MB

Upload Clients Regional Center File or information *

Max file size: 20MB

Upload Clients Regional Center File or information *

Max file size: 20MB

Upload Clients Regional Center File or information *

Max file size: 20MB

Upload Clients Regional Center File or information *

Max file size: 20MB

Upload Clients Regional Center Information or File *

Max file size: 20MB

Case Manager Information

Day Today *

Month *

Date *

Year *

Case Manager or Refering Persons Name *

First

Last

Case Manager or Refering Persons Phone Number *

Referring Agency or Person? *

RCEB E-mail & Phone Number *

SARC E-mail & Phone Number *

Name of referring person or agency if not in our system *

First

Last

Email if not in our system *

Cell Phone Number *

Case Manager Comments *

Thank you for the referral, here is a brief list to please tell your clients to have available at their assessment appointment to verify that we are speaking to the right person.

Examples of what he or she might need:

Your ID (bring ONE of the following)
Driver's license
Birth certificate (for ALL children)
Hospital certificate of birth
State issued non-drivers' ID card
Marriage certificate with date of birth
US passport
Immigration or Naturalization certificate
Medicaid card
Proof of US Citizenship or Legal Residence for each person in household who wants services
Social Security card or number
Immunizations or shot records for all children
School information for all children
Most recent IEP from the school
Most recent Psychological and Behavioral Assessment
Court Documents if you have a pending or open CPS case

For more information about our company would you be interested in visiting our website at www.LeBlancConsulting.net *

Again, thank you so much for the referral and your time. We appreciate you referring your client to LeBlanc Consulting. Have a wonderful rest of your day!

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We Provide Services 24/7
Administrative Office Hours:
Monday - Friday 7:00am-7:00pm
Saturday & Sunday by Appointment Only
We operate on Pacific Standard Time.

Contact us:
Toll FREE: 1(800) 707-1852
North Bay Office: 1(707) 654-8488
North Bay Cell: 1(707) 727-9100
East Bay Office: 1(510) 275-3679
East Bay Cell: 1( 510) 241-9115
South Bay Cell: 1(831) 313-7902
Golden Gate Cell: 1(415) 630-0112
E-mail: [email protected]

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