Referral to Vocational Rehabilitation
The Florida Department of Education, Division of Vocational Rehabilitation (VR) is here to help individuals with disabilities to find, keep, or get a better job. For more information, please complete this form and mail to your VR Area Office or call toll free (800)451-4327. Visit www.RehabWorks.org for a list of area offices.The information on this referral form is being collected pursuant to 34 C.F.R 361.38(a)(1)(iii).Vocational Rehabilitation does not share information without informed written consent.
Contact Information - Required
Name
*
First Name
Last Name
Address (Mailing)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is it a Home or Cell Phone number?
*
Email
*
example@example.com
Additional Information - Optional
Gender
Please Select
Female
Male
Currently enrolled in school?
Please Select
Yes, ASL
Yes Other
Highest Education Level Completed:
Additional Contact Name:
First Name
Last Name
Additional Contact Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
How can VR help you become employed?
How did you hear about us?
Accommodations For Your Initial Appointment
Do you need an Interpreter?
Please Select
Yes, ASL
Yes Other
If other. Please specify language
Do you have translated documents?
Please Select
Yes
No
Do you need an assistive listening device?
Please Select
Yes
No
Do you require any other accommodation(s) for your appointment?
Please Select
Yes
No
If so, please explain:
Student Specific Information – Required for School Based Referrals
School Name:
School District
School Contact Person
First Name
Last Name
School Contact Person Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: