Employment Services Referral Form

Vocational Rehabilitation Services Employment Services Referral Form

Consumer Information Customer Name: DOB: Gender: ID/Seq:

Alternate Address: Phone: Contact:

Resources (e.g., E-Mail: Medicaid, SSI, SSDI, Job Goal BDDS waiver, other (if known): waiver, other [specify]): Severity Level Accommodation Disability: (e.g., MSD, SD, NSD, not yet determined): Needs:

Barriers/ Impediments:

Referral Provider: Date:

VR VR Counselor Counselor: Contact Information:

VR Case VR Case Coordinator Coordinator Contact Information: Services Requested

Situational Work Discovery: Job shadow(s) Other Assessment(s) Experience(s)

Job Readiness Training (please describe specific need):

Employment Services

Employment Service Job Search/ On-the-Job Supported Milestones Placement Assistance Supports – Short-Term Employment Services

Additional comments, special considerations, expectations, transportation options, etc.:

IMPORTANT: Include collateral information such as intake case notes, application information, information learned through Discovery (including, if applicable, the Discovery Profile), evaluations, guardian information, or other information as applicable.