Vocational Rehabilitation Services
Referral for Vocational Assessments
General Instruction
Follow the instructions below when completing this form.
· Refer to the Standards for Providers for additional details;
· Complete the form electronically (on the computer) and answer all questions; and
· Before faxing, emailing encrypted, or mailing to the provider, review this form to ensure that all questions have been answered.
Note: The Vocational Rehabilitation Services staff collects the information and completes all sections of this form.
Provider Chosen by the Customer
Provider name:
Email address:
Provider phone number:
() / Provider fax number:
()
Referral Inforamtion
Date of the referral:
Reason for Referal:
The following job have been discussed with customer:
Referral for: (“x” all that apply)
Vocational Assessment
Combined Situational Assessment and Work Samples
Other: Decribe:
Address these questions in your narrative report (check all that apply):
What is the customer’s present and future vocational potential?
What are the customer’s employment-related strengths and limitations?
Are there any medical or physical concerns, not previously reported, that could affect vocational functioning?
Are there any behavioral concerns that could affect vocational functioning?
Would this person’s job interest be a feasible goal(s)? Why?
What are the transferable job skills that are usable in the current job market?
Do you recommend a formal skills training program?
What general accommodations will enhance this person’s ability to work?
Other: Describe:
Return the Referral to the address listed unter the Counselor Contact Information section below.
Customer Identification Information
Customer name:
Street address (include apartment number, if any):
City: / State: / ZIP code:
Primary contact number:
() / Secondary contact number:
()
Email address:
VRS case ID: / Date of birth:
Customer’s disability:
Alternate Contact Person Identification Information
Alternate contact name:
Alternate contact’s primary contact number:
() / Alternate contact’s secondary contact number:
()
Counselor Contact Information
Counselor name:
Counselor primary VRS office:
Counselor VRS office street address (include suite number, if any):
City: / State: / ZIP code:
Counselor primary contact number:
() / Counselor secondary contact number:
()
Email address:
Additional Information Provided by VRS at Referral
IPE copy
Medical records and/or psychological reports
Psychological evaluation
Progress reports from other programs
Case notes (for example, eligibility, assessment and planning)
Transcripts, other school-related information
DARS5061, Notice and Consent for Disclosure of Personal Information
Other, Decribe:
Other, Decribe:
Additional Comments
Additional comments:
DARS1836 (10/17) Referral for Vocational Assessments Page 1 of 2