Please complete and submit the form below or you can click the button below to download a fillable PDF version you can fill out and email. Click Here To Download a Fillable PDF Version Client Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemale Primary Diagnosis* Secondary Diagnosis Full Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone* Email* Legal Parent / Guardian (if applicable) First Last Relationship to Client Primary Language / Cultural Considerations* Client Basic HealthIs client visually impaired?*YesNo If yes, details: Is client hearing impaired?*YesNo If yes, details: Is client phsyically impaired?*YesNo If yes, details: Other impairments? Please describe here If Applicable - Should we be aware of any Adaptive Devices and/or accommodations needed? Augmentative and Alternative Communication (AAC) Device Ankle Foot Orthotics (AFOs)/Leg, foot or ankle braces Glasses Hearing Aids Wheel chair/walker/forearm crutches Other (describe below) choose all that apply If Other, Please Describe Availability for Vocational Rehabilitation Services Monday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Tuesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Wednesday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Thursday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Friday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Saturday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable Sunday* 7:00 am 8:00 am 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm 6:00 pm 7:00 pm Not Applicable If you currently have VR services, please provide the following information: Vocational Rehabilitation Counselor Name First Last Vocational Rehabilitation Counselor Email Vocational Rehabilitation Counselor Phone CAPTCHA