(YOUTH Pinellas) Vocational-Rehabilitation-Referral-Form

FLORIDA DEPARTMENT OF EDUCATION

Vocational fldoe.org RehabilitationReferral to Vocational Rehabilitation

The Florida Department of Education, Division of Vocational Rehabilitation (VR) is here to help eligible individuals with physical and mental disabilities to find, keep or get a better job. Please complete this page and mail or turn in the referral to the nearest VR office. For a list of offices, go to the VR Website and click on "Contact Us." Then select "Local Office" or call toll free (800)-451-4327. Date of Referral
Date of Referral

MonthDayYear
Date
Name of Individual (Please Print)
Date of Birth

MonthDayYear
Date
Social Security Number
Address (Home)

Address Home

Street Address Line 2

CityState

Zip
Address (Mailing)

Address Mailing

Street Address Line 2

CityState

Zip
Phone Number
Please enter a valid phone number.
HomeCell
Additional Contact Name
Contact Phone Number
Additional Contact Email
example@example.com
What is the best method of contact? (Select one)

EmailMailPhoneOther (Specify)
Can VR leave a message at the number listed?

YesNo
Gender

MaleFemaleDoes not wish to disclose or self-identify
Email Address
example@example.com
Have you ever received services from VR?

YesNo
Education Level
Marital Status

DivorcedMarriedNever MarriedSeparatedWidowed
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoDoes not wish to disclose or identify
Race (Check all that apply)

American Indian/Alaska NativeNative Hawaiian or Other Pacific IslanderAsianWhiteBlack or African AmericanDoes not wish to disclose or self-identify
Accommodations
Do you require an Interpreter?

Yes, ASLYes Other, specify language
Do you require translated documents

Yes
Do you require an assistive listening device?

Yes
Do you require any other accommodations for your impairment?

NoYes, If so please explain
What impairment prevents you from working
How can VR help you become employed
How did you hear about us
AgencyVendorSchool
Contact Person
Phone #
Additional Required Documentation *

(IEP/504/Documented Learning Evaluation)
Cancelof
VR program receives 78.7 percent of its funding through a grant from theU.S.DepartmentofEducation.For the2022 Federal fiscal year, the total amount of grant funds awarded were $175,063,093. The remaining 21.3 percent of the costs ($47,775,094) were funded by Florida State Appropriations. Revised October 2023
FLORIDA DEPARTMENT OF EDUCATION

Vocational RehabilitationReferral to Vocational Rehabilitation

local street address line 1 city, state, zip phoneFax: fax number
Should be Empty:

Accommodations