New Client Interest Form

Thank you for your interest in Guidelight Group services.

We look forward to connecting with you!

First name*

Last name*

Email*

Phone number*

Street address

City*

State/Region

Postal Code

I am a...*

Parent

Self-advocate

Professional

Other

Service recipient information (if you are not the service recipient):

Service recipient name

Service recipient age

Service recipient email

Service recipient phone

Regional Center affiliation

Alta California

Central Valley

East Bay

Eastern Los Angeles

Far Northern

Golden Gate

Harbor

Inland

Kern

Lanterman

North Bay

North Los Angeles County

Orange County

Redwood Coast

San Andreas

San Diego

San Gabriel/Pomona

South Central

Tri-Counties

Westside

Valley Mountain

I'm primarily interested in the following service:*

Life coaching and coordination

Customized employment

Advocacy

Person-centered planning (outside of Self-Determination)

Support to transition into the Self-Determination Program (includes person-centered planning, budget, spending plan) - WAITLIST TEMPORARILY FULL

Independent facilitation for someone already in the Self-Determination Program

We currently have considerable wait times for Self-Determination Program (SDP) services. If you need help with SDP, do you want us to share your contact information with a graduate of our independent facilitator training program if there is someone who might be able to work with you now?

Yes, please share my name and contact information with a graduate of Guidelight Group's independent facilitator training who might be able to work with me.

No, do not share my information.

Message

How did you hear about Guidelight Group?*

Today's date

Month/Day/Year