Supported Employment Referral Form
Name
*
First Name
Last 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?
*
YES
NO
Do you want to work/interested in Integrated Employment?
*
Please Select
YES
NO
Are you 16 years or older?
*
YES
NO
Do you need help finding and or maintaining competitive employment?
*
YES
NO
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 Select
PRIVATE RESIDENCE
RESIDENTIAL CARE
CRISIS RESIDENTIAL
FOSTER HOME
HOMELESS/SHELTER
JAIL CORRECTIONAL FACILITY
INSTITUTIONAL SETTING
CHILDRENS RESIDENTIAL HOME
OTHER
Please list any maiden names and/or other last names, if NONE, identify NONE.
*
Do you have a legal guardian?
*
Please Select
YES
NO
What is your Ethnicity/Race (choose as appropriate)
*
Please Select
AFRICAN AMERICAN
WHITE
HISPANIC
ASIAN
AMERICAN INDIAN OR NATIVE INDIAN
OTHER
How well do you speak English (5years or older)?
*
Please Select
VERY WELL
WELL
NOT WELL
NOT WELL AT ALL
Do you speak another language other than English at home?
*
Please Select
YES
NO
Do you need assistance communicating in English?
*
Please Select
YES
NO
Primary Source of Income?
*
Please Select
WAGES SALARY
PUBLIC ASSISTANCE
SELF EMPLOYMENT
RETIREMENT
UNEMPLOYMENT
DISABILITY
NONE
OTHER
UNKNOWN
Type of Insurance?
*
Medicaid #
*
Highest level of school completed?
*
Is the Individual a Veteran?
*
YES
NO
Does the individual have full Developmental Disabilities Administration (DDA) eligibility?**
*
YES
NO
Does the individual have an existing DORS case open?
*
YES
NO
Source of the diagnosis (Diagnosing Clinician or Clinical Supervisor information)?
*
First Name
Last Name
Source of the diagnosis CREDENTIALS
*
Please Select
APRN-PMH/CRNP-PMH
LCPC
LCSWC
LCMFT
LCADC
LCAPT
PHD/PSYD
MD/DO
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)
*
Problems with access to health care services
Problems related to the social environment
Educational problems
Housing problems (not Homelessness)
Problems related to interaction w/legal system/crime
Occupational problems
Homelessness
Financial Problems
Problems with primary support group
Medical disabilities the impact diagnosis or must be accommodated for in treatment
Other Psychosocial Problems
Unknown
Other
Disability Status: All Questions Must be answered Is the individual deaf or have serious difficulty hearing?
*
YES
NO
Because of a physical, mental, or emotional condition, does the individual have serious difficulty concentrating, remembering, or making decisions?
*
YES
NO
Does the individual have difficulty dressing or bathing?
*
YES
NO
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)
*
YES
NO
Does the individual have serious difficulty walking or climbing stairs?
*
YES
NO
Is the individual blind or have serious difficulty seeing, even when wearing glasses?
*
YES
NO
Additional Information, if applicable?
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: