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GOVERNMENT OF THE VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES VOCATIONAL REHABILITATION PROGRAM DIVISION DISABILITIES & REHABILITATION SERVICES 3011 Golden Rock C’sted Knud Hansen Complex Croix, V.1. 00820-4355 1303 Hospital Ground, STE. 1 (Tel.) 340-773-2323 St. Thomas, V.I. 00802-6722 (Fax) 340-773-3641 Referral Information (Tel.) 340-774-0930 (Fax) 340-774-7773 [_] Vocational Rehabilitation [_] Independent Living C] 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 —S—- Yes__—‘« Card Number Health Insurance No_—s- Yes____ Name of Company (ies) Public Assistance Nos 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