/ Texas Workforce Commission
Vocational Rehabilitation Services
Supported Employment Services Referral

Instructions

Follow the instructions below when completing this form.
  • Refer to the TWC VR Standards for ProvidersChapter,Supported Employment Services,for details.
  • Complete the form electronically answering all questions.
  • Before faxing, emailingencrypted, or mailing to the provider, review this form to ensure that all questions have been answered.
Note:The VRS staff collects the information and completes all sections of this form.

Referral

Date of Referral:
Referral for:Supported Employment Services
Autism Service Premium / Deaf Service Premium
Other Service Premium, Specify:

Customer Identification Information

Customer Name:
Street address (include apartment number if applicable):
City: / State: / ZIP code:
Primary contact number:
() / Secondary contact number:
()
Email address:
VRS Case ID: / Date of birth:
Customer disability:

Alternate Contact Person Identification Information

Alternate contact’s name:
Alternate contact’s relationship to customer:
Alternate’s primary contact number:
() / Alternate’s secondary contact number:
()

Additional Information Provided by VRS at Referral

Select all that apply.
IPE copy / Vocational testing
Medical and/or psychological reports / Work history collected by VRS
Case notes (for example, eligibility, assessment and planning) / Work references collected by VRS
Benefits Planning Reports from Community Work Incentive Coordinator (CWIC)s / Functional Capacity Exam Results
Other: / Other:

VR Counselor Contact Information

VR counselor’s name:
VR counselor’s primary VRS office:
VR counselor’s VRS office street address (include suite number, if applicable):
City: / State: / ZIP code:
VR counselor’s primary contact number:
() / VR counselor’s secondary contact number:
()
Email address:

Provider Chosen by the Customer for Services

Provider’s name:
Email address:
Provider’s phone number:
() / Provider’s fax number:
()

Supported Employment Service Plan Meeting

Location:
Date: / Time:

Extended Services

VRS is responsible for assisting with the identification of Extended Services funders and/or providers for customer in Supported Employment. Identify below the comparable benefits and/or potential Extended Services funders or providers available to the customer.
Waivers:
None
Home and Community Services (HCS)
Texas Home Living (TxHML)
Community Living Assistance and Support Services (CLASS)
STAR+PLUS
Deaf Blind with Multiple Disabilities (DBMD)
Other:
Note: Extended Services need to be recorded within the applicable Waiver Plan to ensure an employment goal and long-term employment support needs are available post closure with VRS.
The VR counselor needs to contact the customer’s waiver service coordinator or case manager to gain a copy of all applicable Waiver Plan(s). Waiver Plan should be given to the VRS Supported Employment Provider.
Wavier Plan attached
Person-directed plan (PDP) / Individual plan of care (IPC) / Individual service plan (ISP)
Other:
Social Security Work Incentives:
None
Plan to Achieve Self-Support (PASS)
Impairment Related Work Expenses (IWRE)
Other:
Community Resource(s): (list and describe) / None (if no community resources are available)
Natural Support(s): (list and describe) / None (if no natural resources are available)

Additional Comments

Additional comments (if any):

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