Department of Workforce Services
Office of the Director
614 South Greeley Highway
Cheyenne, Wyoming 82007
307.777.8650 § Fax: 307.777.5857
www.wyomingworkforce.org /
Matthew H. Mead
Governor / John Cox
Director
John Ysebaert
Deputy Director
STATEMENT OF APPLICATION
Dear: Date:
This letter is to confirm that you applied for Vocational Rehabilitation Services on ______. Your Rehabilitation Counselor has up to 60 days from today to obtain the required diagnostics and other information to determine if you are eligible for services. If additional time is necessary, it must be with your consent.
During the eligibility period you will be asked to sign a release of information form so that additional information can be gathered. Additional tests, exams and evaluations may be necessary to determine if you qualify for Vocational Rehabilitation services. You will be notified of the Eligibility decision.
If you are eligible to receive Vocational Rehabilitation services, you and your Rehabilitation Counselor will jointly develop an Individualized Plan for Employment (IPE).The IPE includes your vocational goals and services that will be provided in order to achieve those goals. It is important that you actively participate in the development of your IPE and the implementation of your rehabilitation services.
If you are not satisfied with the decisions concerning the delivery or denial of services, you can request a timely review of those decisions to include a hearing to be conducted before an impartial hearing officer with 45 days of the request. A written appeal must be received by the DVR Administrator within 20 days of the contested action. Your Rehabilitation Counselor will provide the phone number of the Regional Manager or you can call (307)-777 7389 for more information. You could also call the Client Assistant Program at 1-800-821-3019 or (307) 638-7302 for Cheyenne and TDD users to discuss any problems or concerns.
PROFESSIONAL DISCLOSURE
The purpose of public vocational rehabilitation is to assist eligible persons with disabilities in finding an appropriate job. This job may be returning to your last job or getting a job in a new field. You and your Rehabilitation Counselor will work together to find employment that you are physically and mentally able to do that is as close as possible to your vocational goal.
You will be assigned a person who is a qualified Rehabilitation Counselor or is being supervised by one. If you feel the Rehabilitation Counselor has acted in an unethical manner, you should contact the Rehabilitation Counselor’s immediate supervisor or the Commission on Rehabilitation Counselor Certification.
One very important part of your relationship with your Rehabilitation Counselor is confidentiality. Personal information related to your rehabilitation services will be recorded in your file. This information will be kept private except as follows:
· If you have signed a release of information that allows the information to be shared.
· If your Rehabilitation Counselor believes you are going to harm yourself or others, he/she is required to notify the endangered individual(s) and the proper authorities.
· In response to certain investigations in connection with law enforcement, fraud or abuse.
· If your Rehabilitation Counselor believes you are going to harm or abuse children or the elderly, he/she must report this to state or local authorities.
· If your Rehabilitation Counselor or this agency is sued or court ordered and a properly issued subpoena is received, then information in your file may be released.
· If you are a minor or not your own legal guardian, then information in your file may be available to your legal guardian or advocate.
It is important to remember that the goal of the Rehabilitation Counselor is to help you get a satisfactory job and services must be related to that goal. It is also important to know that the Rehabilitation Counselor, will at all times, try to act in your best interest and protect you from unnecessary risk. Before signing this form, your Rehabilitation Counselor will review the following topics with you.
· The Rehabilitation Counselor’s roles and responsibilities.
· Your roles and responsibilities.
· Goals and types of services provided or not provide.
· Legal issues affecting services.
· Who to contact in the event the RC is unavailable.
· Risks and benefits of services.
WY Division of Vocational Rehabilitation does not discriminate against any person on the basis of disability, age, sex, color, ethnic group, race, national origin, ancestry, religion, medical condition, sexual orientation, or marital status in admission to, participate in, or receipt of the services and benefits under any of its programs and activities. For further information about this policy, call 307-777-6271 or 7-1-1 or 800-877-9965 (TTY).
By signing this form, I agree that I have discussed the above information with my Rehabilitation Counselor and that I understand the information we discussed as well as the information found within this document.
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Signature of Client Date
______
Signature of Legal Guardian Date
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Signature of the Rehabilitation Counselor Date
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