- Step 1 of 5Referred for ServicesPRE-ETSJRTCWATPSATCAREER ORIENTATION/JOB SAMPLINGPLACEMENTSUPPORTED EMPLOYMENT (TRADITIONAL)TRAININGSJOB COACHINGJOB READINESS TRAININGPERSONAL/SOCIAL ADJUSTMENT TRAININGWORK ADJUSTMENT TRAININGASSESSMENTSCOMPREHENSIVE VOCATIONAL EVALUATIONVOCATIONAL EVALUATION LIMITED TRAVELPROVIDER TRAVEL (TIME AND MILES) NextGeneral InformationDate / TimeReferring Agency/Location *Primary Clinical Contact and Title *Primary Clinical Contact Email *EmailConfirm EmailReferring Agency Mailing Address *Address Line 1CityGeorgiaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReferring Agency Phone *Referring Agency FaxNextClient InformationClient Case NumberClient Name *FirstMiddleLastAgeDate of BirthSSNRaceSexMarital StatusClient Address (Mailing) *Address Line 1CityGeorgiaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClient Address (Residential)Address Line 1CityGeorgiaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeTelephone (Home)Telephone (Work)Telephone (Emergency)Email *EmailConfirm EmailParent/Guardian/Next of Kin: *FirstLastComplaint/Presenting Problem (reason for referral) *NextBackground InformationResidenceInpendentlyAssistive LivingGroup HomeFamilyPrimary DisabilitySecondary DisabilityPrimary Mode of CommunicationAmerican Sign LanguagePidgin Sign LanguageSign Exact EnglishTactile Sign LanguageMinimal LanguageOralWrites/types EnglishOtherCan client travel to Bright Thinkers Office for interview, PSAT or JR training?YesNoHow will client travel to job site?Own CarBusFamily/Friend DriverWalkOtherPrimary/Emergency Contact *FirstLastRelationship: *Address (if different from client)Address Line 1Address Line 2CityGeorgiaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail Address *Phone (Cell):Phone (Home)Has client clearly demonstrated a desire to work? *YesNoDoes the client, parents and/or guardian support the employment placement and understand the impact it will have on Social Security Benefits? *YesNoClient's GoalReferring Counselor's ExpectationNextEmployment Skills Program Job Coaching – Worksite Itinerary InformationName of CompanyAddressAddress Line 1CityGeorgiaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWorksite Supervisor's Name *Supervisor’s Phone NumberDate and Time for Job Coach to Begin WorkDateTimeClient’s Work Hours (Begins) AM/PMClient’s Work Hours (ENDS) AM/PMSpecial Employment Issues to Focus on:GDPR Agreement *I consent to having this website (Bright Thinkers) store my submitted information so they can respond to my inquiry.CommentSubmit Referral Form