Bundled Job Placement Services—Referral
General Instructions
Follow the instructions below when completing this form:
· Refer to the DRS Standards for Providers for additional details;
· Complete the form electronically answering all questions; and
· Before faxing, emailing encrypted, or mailing to the provider, review this form to ensure that all questions have been answered.
Note: The DARS staff collects the information and completes all sections of this form.
Date of the Referral: 05/01/2014
Referral for: X Bundled Job Placement Services
A. Consumer Identification Information
Consumer’s name:
Ralph
Street address (include apartment number, if any):
555 Cow Buster Rd
City:
Austin / State:
TX / ZIP code:
78787
Primary contact number:
(817) 212-3456 / Secondary contact number:
(817) 333-3333
Email address:
DARS Case ID:
78945613 / Date of birth:
1-5-1969
Consumer disability:
Major depressive disorder
B. Alternate Contact Person Identification Information
Alternate contact’s name:
Ralph's wife (Nina)
Alternate’s primary contact number:
(817) 453-6789 / Alternate’s secondary contact number:
(817) 555-5555
C. Additional Information Provided by DARS at Referral
Enter X to select all that apply.
x IPE copy / Vocational testing
x Medical and/or psychological reports / x Work history collected by DARS
x Case notes (for example, eligibility, assessment and planning, etc.) / Work references collected by DARS
x Benefits Planning Reports from CWICs / Functional Capacity Exam Results
Other: / Other:
D. Counselor Contact Information
Counselor’s name: Happy Counselor
Counselor’s primary DARS office:Ft Worth West
Counselor’s DARS office street address (include suite number if any):
56787 West Fwy
City:
Fort Worth / State:
TX / ZIP code:
78787
Counselor’s primary contact number:
(817) 111-1111 / Counselor’s secondary contact number:
(817) 000-0000
Email address:
E. Provider Chosen by the Consumer for Placement Services
Provider’s name:
Best Provider
Email address:
Provider’s phone number:
(817) 323-5555 / Provider’s fax number:
(817) 323-5555
F. Bundled Job Placement Service—Plan Meeting
Location:
DARS office
Date: 5/15/14 / Time: 10 am
G. Additional Comments, if any
Additional Comments:
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