Overview

Career Training Services

Rehabilitation and Vocational Services

Referral Process

Referral Form

Application Form

What our Trainees have said 

Employment Skills Training Links

Consumer Referral Form
Consumer's Information
Full Name:
Last
First
M.I.
Date of Birth: / /
01/01/1950
Social Security #: XXX-XX-
Last Four Digits
Address:
Street Address

Apt./Unit #

City
State
Zip Code
Phone:( )
(Area Code) + 7 digits with no hyphens
 		Email:   
Phone #2:( )
(Area Code) + 7 digits with no hyphens
Services and Goals
Type of Service:
Career Goal:
Consumer's Disability:
Has Consumer received services from DARS before? Yes No
If yes, date: / /
01/01/1950 

Please check or indicate document(s) to be forwarded: 
  Purchase Order-Provider Invoice
Individualized Plan for Employment (IPE)
Copies of relevant case notes (including initial contact)
 Medical records summaries or as appropriate
 Psychological evaluations
 Transcripts and/or other school-related information
 Social evaluation
 Other:
Referring Counselor's Contact Information
Name:
Referring Counselor's Full Name		 Phone:( )
(Area Code) + 7 digits with no hyphens
Office:
Office Location		 Fax:( )
(Area Code) + 7 digits with no hyphens
RT Name:
Rehabilitation Technician's Full Name
RT Phone: ( )
(Area Code) +7 digits with no hyphens

If you want a copy of this form, must print before selecting 'submit'