Referral Form
Edison #0000272232
Customer Information
Customer Name
*
First Name
Last Name
Customer Email
*
example@example.com
Customer Phone Number
*
Please enter a valid phone number.
Customer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Customer Preferred Method of contact:
*
Phone Voice
Phone Deaf Services
Text Message
Email
Other (specify in the Supported Goal Section)
Supported Goal of Customer or other important information:
*
Referring Counselor Information
Counselor Name
*
First Name
Last Name
Counselor Email
*
example@example.com
Counselor Phone Number
*
Please enter a valid phone number.
Assessments and Evaluations
Assessments/Evaluations Select all to perform
Abilities360 Evaluation (full evaluation on customer needs including occupational interest survey) $1,000
Tennessee Business Enterprise Evaluation $633
Braille Evaluation $633
Communications and Home Management Evaluation $633
Vocational Evaluation $633
Other Single Service Evaluation (i.e. AT Eval, Low Vision Lighting and Filters and more.) $633
College Readiness Evaluation $900 (Testing on Reading comprehension, math skills, computer literacy, note-taking skills, and more.)
Virtual Assistive Technology Evaluation (Indiana Only) $700
Please specify:
Skills Training
Type a question
HiSet Exam Preparation Virtual/In Person($1800 per month/5 month program)
Access Technology Skills Training Virtual/In Person ($75 per hour)
BrailleQuest Program (Beginning Braille Instruction $75 per hour)In person only
Microsoft Word Mastery Virtual/In Person $1800/mo
Microsoft Excel Mastery Virtual/In person $1800/mo
Microsoft Outlook/Teams Mastery Virtual/In Person Virtual/In Person $1800/mo
Microsoft OneNote Mastery Virtual/In Person $1800/mo
Computer Literacy Skills Training ($1800/ 20 hours per month)
Google Workspace Virtual/In Person $1800 per month
Other
Specify:
Employment Training Services
Check all approved services for this customer. (Visit www.VisionLinkSolutions.com for program descriptions)
CollegeConnect: College Support Program Virtual only (semester program) Contact Vendor for pricing Meredith@VisionLinkSolutions.com)
CollegeConnect: College Preparation $1800/mo Virtual/In person (3 month program)
Access Technology Instructional Specialist Training Virtual/ In Person (CATIS Preparation) $1800/month
ServSafe Certification ($1800 includes exam)
CareerBridge Program Virtual/In Person ($1800/mo)
Self-Employment Preparedness Program Virtual/In Person ($1800/mo)
Other
Specify:
By submitting this referral form you are agreeing to supply an authorization within 1 week of submission for the above service. If a service is not listed above and/or you are unsure of which program to select please contact Meredith at 615-266-4030 or Meredith@VisionLinkSolutions.com
Submit
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