wp content uploads 2023 03 VocRehab Referral Form
No. 2 Estate Carlton, Suites 4 & 7 Frederiksted, VI 00840 (Tel.) 340-643-8145 (Tel.) 340-626-6268 Knud Hansen Complex 1303 Hospital Ground, STE. 1 St. Thomas, V.I. 00802-6722 (Tel.) 340-774-0930 (Fax) 340-774-7773 GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES VOCATIONAL REHABILITATION PROGRAM DIVISION DISABILITIES & REHABILITATION SERVICES Referral Information Vocational Rehabilitation Independent Living Pre-Employment Transition Services Name: _____________________________ Sex ______ Social Security No.______________________________ Date of Birth _________________ Age _______ Place of Birth _________________________________________ Citizenship Status ___________________ Alien Regis. No. ______________Occup. ________________________ Home Address _________________________________ Mailing Address_________________________________ Tel. No. …
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No. 2 Estate Carlton, Suites 4 & 7 Frederiksted, VI 00840 (Tel.) 340-643-8145 (Tel.) 340-626-6268 Knud Hansen Complex 1303 Hospital Ground, STE. 1 St. Thomas, V.I. 00802-6722 (Tel.) 340-774-0930 (Fax) 340-774-7773 GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES VOCATIONAL REHABILITATION PROGRAM DIVISION DISABILITIES & REHABILITATION SERVICES Referral Information Vocational Rehabilitation Independent Living Pre-Employment Transition Services Name: _____________________________ Sex ______ Social Security No.______________________________ Date of Birth _________________ Age _______ Place of Birth _________________________________________ Citizenship Status ___________________ Alien Regis. No. ______________Occup. ________________________ Home Address _________________________________ Mailing Address_________________________________ Tel. No. Work _____________ Home______________ Cell ____________________Email___________________ Person to notify of emergency____________________________________________________________________ Referred By __________________________________ Date of referral __________________________________ Statement of Disability _________________________________________________________________________ Type of service requesting_______________________________________________________________________ Social Security Beneficiary No____ Yes____ Workman’s Compensation______________________ Medical Assistance No____ Yes____ Card Number ________________________________ Health Insurance No____ Yes ____ Name of Company (ies) _______________________ Public Assistance No____ Yes ____ Type of Service _____________________________ Name & Address of client Physician _______________________________________________________________ Name & Address of referral source or organization____________________________________________________ * Professional personnel referring client, when possible please obtain release from client or guardian attach pertinent medical, psychiatric, psychological, or education information. FOR VOCATIONAL REHABILITATION USE ONLY Referral Taken by: Assigned to: Date: Note to counselor: As a professional courtesy to doctors, professional service workers, agencies or organization making referral, please fill out and send to “Report Back to Referral Source” form at the end of the evaluation process. DRS-VR 05-2017 Referral Form