Forms

You can download NVRA (National Voter Registration Act) Voter Preference Forms by clicking here 

Client Referral Form  – Use this form to initiate new client referrals to CVRC
Online Client Referral Form – Use this online referral to go to the paperless

Consent to Assess
Request of Information

Intake Assessment Worksheet    English  –  Spanish

Unannounced Visit Form

Supported Living Services (SLS) Standardized Assessment Questionnaire

Vendor/Provider Forms

Notification Requirements for Confidential Information Breaches for Vendors, Employees, Contractors, or Researcher

  • State policy requires that vendors, employees, contractors, or researchers report any privacy breaches (e.g. stolen computer equipment with client information on it or client paper records left in a public place).
  • The Information Security Incident Report (SIMM 5340-B) contains all of the required reporting information.
  • Instructions for filling out the form are located below.
  • All sections of the form MUST be completed. Signature is required on the form.
  • A SAMPLE breach letter MUST be included for reporting responsibilities to be considered complete.
  • The form is located below and can be completed in Microsoft Word and emailed to Cris Guzman (cguzman@cvrcold.betaplanets.com)
  • Or printed out and mailed to: Central Valley Regional Center, 4615 N. Marty, Fresno, CA 93722, Attn: Cris Guzman
  • Mr. Guzman can be reached at (559) 276-4333 to answer any questions.
  • The form MUST be completed and sent within 72 hours of learning of a suspected privacy breach or security incident.