Community Behavioral Health Services

Community Behavioral Health Services

Vocational Referral Form

CVE RAMS Hire-ability TVP

Section I: Client SectionDate: ______

1. Name:

First Name
Middle Name
Last Name

2. Social Security Number: ______-______-______

3. Address: ______City:______State: CA Zip Code:______

4. Date of Birth: _____/_____/_____

5. What are your Vocational Goals?

Paid Employment Training/Education Volunteering

Please Explain: ______

______

6. Contact Information:

Home Number: (____)______Cellular Number: ( ) ______

Email:______Other Number: (___)______

7. Gender:

Male Female Transgender

8. Ethnicity:

African American Asian/Pacific Islander Caucasian Chinese

Filipino Hispanic/Latino/a Native American/Alaskan Native

Multi-ethnic Other:______

9. Primary Language: ______

Client Signature:______Date: ______I authorize the information on this referral form to be released and exchanged by the referring agency.

Client Name:______

Section II. Clinician Section

10. BIS Number: ______

11. Diagnosis:

Axis I: [ ] ______

Axis II: [ ] ______

Axis III: [ ] ______

Axis IV: ______

Axis V: ______

12. Medications:

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

Clinician Signature: ______Date: ______

13. Date last hospitalized: ______

14. List any medical issues:

1. ______4. ______

2. ______5. ______

3. ______6. ______

15. Does the client have a history of substance abuse/alcohol?

Yes, currently (list frequency and types): No

1. ______
2. ______
3. ______

Yes, in the past (list of frequency and types): No

1. ______
2. ______
3. ______

Is the client clean and sober now?

Yes, Years ______Months ______

No

Client Name: ______

16. Does the client have any known history of violence?

No

Yes, how long ago? ______

Please explain: ______

______

17. Is the client on probation or parole? Yes No

If yes, please provide the parole office contact information? ______

18. Precipitators that lead to acute symptomatology (red flags)/Reaction to Stress (client response to red flags):

______

19.Support System: ______

______

20. Suggested strategies and/or reasonable accommodations for working with this client: ______

______

______

21. Vocational Performance Strengths/Challenges (this list is particularly significant in vocational planning):

______

22. Occupations or situations to be avoided: ______

______

23. Ability to tolerate full day of employment or training (Please explain any health issues that may impact work tolerance): ______

______

24. Coping skills/ability to manage change/ability to work and get along with others ability to accept feedback:

______

25. Ability to work independently: ______

26. Motivation and cooperation: ______

27. Education Level – learning, reading and writing ability: ______

28. The barriers to employment e.g.: cognitive difficulties, developmental disabilities, hygiene and concentration deficit: ______

______

Client Name: ______

Provider Support System:

Referring Counselor
Agency / Phone Number
Fax Number / Email
Psychiatrist / Phone /Email
Case Manager / Phone/Email
Therapist / Phone /Email
Conservator: / Phone /Email
Other / Phone /Email
Emergency Contact:
Name / Relationship
Phone / Email

For referral to CVE, Inc., - 1425 Folsom St, San Francisco, CA 94103

Phone: [415] 544-0424

Fax:[415] 544-0351

For referral to Transitional Volunteer Program [TVP] – 1675 California St, San Francisco, CA 94109

Phone: [415] 982-8999

Fax: [415] 982-0890

For referral to RAMS, Inc., - Hire-Ability, 1234 Indiana St, San Francisco, CA 94107

1. Please Fax (415-920-6877) this form to the Intake Coordinator along with:

-Face Sheet, Admission Assessment and most recent medication sheet. Questions on these forms please call: 415-282-9675 x207

2. Which of the following services would best fit the needs of your client?

Employee Development Program – ED (needs job training/basic work skills development)

Employment Services Program – ES (wants to be placed/receive support in the open job market)

Café Phoenix – Food Service Program (wants to receive training in a kitchen or café setting)

Work Adjustment (needs intensive work skill development. 1:5 ratio. Time limited)

Janitorial (wants to receive certificate in janitorial)

I-ability (wants to receive certificate in information technology)

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