Form

I am Interested in Selecting My Own Care Provider

You can select your own care provider, and they will be paid for the hours they work providing care for your family. There is no cost to you if you qualify through your local California Regional Center.

Care providers can be friends, family members, neighbors, or anyone else you trust. You can even designate multiple care providers to maximize scheduling flexibility and make sure you’re able to use all of your authorized care hours from your Regional Center.

Point of Contact First Name *

Point of Contact Last Name*

Email Address*

Phone Number

Person Served First & Last Name (client/dependent)*

Person Served Date of Birth*

What Regional Center Do You Belong To?

What is the Name of your Service Coordinator (n/a if unknown)*

Service Coordinator Contact Information (n/a if unknown)

I authorize that all information provided on this form, including any and all personal data, may be shared with 24 Hour Home Care and my regional center to facilitate the next steps to sign onto care services. This data will be securely retained indefinitely.