Dental Desensitization

Complete this form if you would like help for yourself or someone you provide care for to register for the dental desensitization program.

Question Title

* 1. ACRC Client Name

Question Title

* 2. ACRC Client birthdate

Birth date

Date

Question Title

* 3. Name of person completing this form

Question Title

* 4. Relationship to client

Self

Parent

Caregiver

Service Coordinator

Other (please specify)

Question Title

* 5. Phone number

Question Title

* 6. Email address

Question Title

* 7. Name of Client's Alta California Regional Center Service Coordinator (If unknown, contact Alta California Regional Center at (916) 978-6400 to get this information)

Question Title

* 8. Email address of Alta California Regional Center Service Coordinator