Regional Center of the East Bay

Offering RCEB Families:

Service Service Code Vendor Number
Employer of Record Daycare (EOR)
62 HB0920

EOR Daycare Services - Referral Form

You can obtain a PDF copy of this Referral Form here: Click to Download

To be completed by a case manager only

Fill out the following information and submit it electronically or download a hard copy and mail, fax, or email to our office.

Once we receive the referral, our office will contact the family by sending out an EOR Welcome packet or conducting an intake to assess the family's needs.

Consumer

Name
UCI Number
DOB
Gender

Parent

Parent / Guardian's Name
Email
Address
City, State, & Zip
Phone Number
Parent Language
Does the family have an interpreter?

Service Coordinator

Name
Phone
Email

POS

Total # of Respite Hours
Frequency of Hours
Additional Instructions

By hitting the submit button, the referral form will be sent directly to admin@pacifichomecare.com. When we receive the referral form we will send an email with a receipt of confirmation notice.

You can obtain a PDF copy of this Referral Form here: Click to Download