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. Client Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemale Diagnosis* Full Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Legal Parent / Guardian (if applicable) First Last Relationship to Client Primary Phone (Client)* Primary Phone Type (Client)* Mobile Home Primary Phone (Legal Guardian) Primary Phone Type (Legal Guardian) Mobile Home Primary Email (Client)* Primary Email (Legal Guardian) Primary Language / Cultural Considerations* 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 What specific Employment Services are you wanting through HOPE Group?* JDR: Job Development & Retention (VR) RIS: Rehabilitative Instructional Services (VR) CE: Career Exploration (VR) choose all that apply Who is your state assigned Support Coordinator and/or Vocational Rehabilitation Counselor? DDD Support Coordinator (First & Last Name) First Last DDD Support Coordinator Phone DDD Support Coordinator Email Vocational Rehabilitation Coordinator Name First Last Vocational Rehabilitation Coordinator Phone Vocational Rehabilitation Coordinator Email Does client transport themselves?* Yes No If no, please provide client's primary method of transportation Vocational Rehabilitation services are provided in person as well as virtually, what is the client’s preference?* All in-person In person and virtual (hybrid) All virtual Please provide the desired outcome through employment services Employment Services AvailabilityPlease enter your time availability for each day below Monday* If no availability, please type NA Tuesday* If no availability, please type NA Wednesday* If no availability, please type NA Thursday* If no availability, please type NA Friday* If no availability, please type NA Saturday* If no availability, please type NA Sunday* If no availability, please type NA CAPTCHA