<p> Vocational Rehabilitation Services Employment Services Referral Form</p><p>Consumer Information Customer Name: DOB: Gender: ID/Seq:</p><p>Alternate Address: Phone: Contact:</p><p>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:</p><p>Barriers/ Impediments:</p><p>Referral Provider: Date:</p><p>VR VR Counselor Counselor: Contact Information:</p><p>VR Case VR Case Coordinator Coordinator Contact Information: Services Requested</p><p>Situational Work Discovery: Job shadow(s) Other Assessment(s) Experience(s)</p><p>Job Readiness Training (please describe specific need):</p><p>Employment Services</p><p>Employment Service Job Search/ On-the-Job Supported Milestones Placement Assistance Supports – Short-Term Employment Services</p><p>Additional comments, special considerations, expectations, transportation options, etc.:</p><p>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.</p>