Vocational Rehabilitation Program Referral Form

Referred for Services

PRE-ETS

JRT
CWAT
PSAT
CAREER ORIENTATION/JOB SAMPLING

PLACEMENT

SUPPORTED EMPLOYMENT (TRADITIONAL)

TRAININGS

JOB COACHING
JOB READINESS TRAINING
PERSONAL/SOCIAL ADJUSTMENT TRAINING
WORK ADJUSTMENT TRAINING

ASSESSMENTS

COMPREHENSIVE VOCATIONAL EVALUATION
VOCATIONAL EVALUATION LIMITED

TRAVEL

PROVIDER TRAVEL (TIME AND MILES)

General Information

Date / Time

Referring Agency/Location *

Primary Clinical Contact and Title *

Primary Clinical Contact Email *

Email

Confirm Email

Referring Agency Mailing Address *

Address Line 1

City

State

Zip Code

Referring Agency Phone *

Referring Agency Fax

Client Information

Client Case Number

Client Name *

First

Middle

Last

Age

Date of Birth

SSN

Race

Sex

Marital Status

Client Address (Mailing) *

Address Line 1

City

State

Zip Code

Client Address (Residential)

Address Line 1

City

State

Zip Code

Telephone (Home)

Telephone (Work)

Telephone (Emergency)

Email *

Email

Confirm Email

Parent/Guardian/Next of Kin: *

First

Last

Complaint/Presenting Problem (reason for referral) *

Background Information

Residence

Inpendently
Assistive Living
Group Home
Family

Primary Disability

Secondary Disability

Can client travel to Bright Thinkers Office for interview, PSAT or JR training?

Yes
No

Primary/Emergency Contact *

First

Last

Relationship: *

Address (if different from client)

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Phone (Cell):

Phone (Home)

Has client clearly demonstrated a desire to work? *

Yes
No

Does the client, parents and/or guardian support the employment placement and understand the impact it will have on Social Security Benefits? *

Yes
No

Client's Goal

Referring Counselor's Expectation

Employment Skills Program Job Coaching – Worksite Itinerary Information

Name of Company

Address

Address Line 1

City

State

Zip Code

Worksite Supervisor's Name *

Supervisor’s Phone Number

Date and Time for Job Coach to Begin Work

Date

Time

Client’s Work Hours (Begins) AM/PM

Client’s Work Hours (ENDS) AM/PM

Special Employment Issues to Focus on:

Vocational Rehabilitation Program Referral Form

Referred for Services

General Information

Client Information

Background Information

Employment Skills Program Job Coaching – Worksite Itinerary Information

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