Dayle McIntosh Center: Visually Impaired Client 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.

Visually Impaired Vocational Services Client Referral Form

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

Referral to:
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:
Vocational Goal:
Four-Digit Disability Code:
Primary Disability:
Type of Visual Impairment:	MD RP Cataracts Other:
Secondary Disability:
Braille Reader?	Yes—Grade 1 Yes—Grade 2 No
Mobility:	None Uses Guide Dog Uses Cane
Computer AT Knowledge: (if applicable)	None JAWS ZoomText Other:
Date of Last AT Assessment/Evaluation: (please send separately)
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 this referral: AT Assessment/Evaluation Psychological or Medical Evaluation Vision Examination Mobility and/or Vocational Training Evaluation or Notes Authorization for Service

Additional Comments:	Additional Comments

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