Supported Employment Referral Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Have you been diagnosed with a mental disorder?

Do you want to work/interested in Integrated Employment?

Are you 16 years or older?

Do you need help finding and or maintaining competitive employment?

What name do you prefer to be called?

Please last any maiden names and/or other last names, if NONE, identify NONE.

What is your current living situation? (Choose as appropriate)*

Please list any maiden names and/or other last names, if NONE, identify NONE.

Do you have a legal guardian?

What is your Ethnicity/Race (choose as appropriate)

How well do you speak English (5years or older)?

Do you speak another language other than English at home?

Do you need assistance communicating in English?

Primary Source of Income?

Type of Insurance?

Medicaid #

Highest level of school completed?

Is the Individual a Veteran?

Does the individual have full Developmental Disabilities Administration (DDA) eligibility?**

Does the individual have an existing DORS case open?

Source of the diagnosis (Diagnosing Clinician or Clinical Supervisor information)?

First NameLast Name

Source of the diagnosis CREDENTIALS

Email of Diagnosing Clinician

example@example.com

Telephone number of Diagnosing Clinician

Please enter a valid phone number.Format: (000) 000-0000.

Social Elements Impacting Diagnosis (check all that apply)

Disability Status: All Questions Must be answered Is the individual deaf or have serious difficulty hearing?

Because of a physical, mental, or emotional condition, does the individual have serious difficulty concentrating, remembering, or making decisions?

Does the individual have difficulty dressing or bathing?

Because of a physical, mental, or emotional condition, does the individual have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older)

Does the individual have serious difficulty walking or climbing stairs?

Is the individual blind or have serious difficulty seeing, even when wearing glasses?

Additional Information, if applicable?

Signature

Date