Dayle McIntosh Center: Fountain Valley Referral Form

Vocational Services:
Our Mission

We provide Department of Rehabilitation counselors with a strong partnership based on honesty, communication and trust with mutual goals of assisting individuals with disabilities in obtaining, retaining, and advancing in their chosen careers.

For additional forms, see the Referral Forms main page.

Fountain Valley Referral Form

Please fill out the form completely, then click the Submit Form button below.

Referral to:	Dolores Kollmer
D. R. Counselor Name:
D. R. Counselor E-mail:
Phone:
Date:

Client Name:
SS #:
D.O.B.:
Address:	Client Address
Phone:
Mes. Phone:
E-mail:
Severely Disabled:	Yes No
Vocational Goal:
Four-Digit Disability Code:
Primary Disability:
Secondary Disability:
Functional Limitations:	Functional Limitations
Selective Placement and/or Special Assistance Necessary? (Deaf, Speech Problems, Visual Impairment, Slow Learner, etc.)	Yes No
If YES, please specify:
Funding Sources:	SSI SSDI SDI GR VA TANF
Current Medication:
Substance Abuse History:	Yes No
How Long Sober?
Criminal History:	Criminal History

Please Send the Following Information Separately to Complete Referral: Psychological Evaluation Medical Evaluation Vocational Training for Employment Authorization for Case Service Contract

Additional Comments:	Comments

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