Embarking on the journey of seeking assistance through the Division of Disability, Aging, and Rehabilitative Services can be a crucial step for individuals striving for a more inclusive and accessible future. The State Form 10057, known as the DDARS Referral and Application, serves as a gateway for accessing a range of services tailored to individuals with disabilities. Guided by the Civil Rights Act of 1964, this form encapsulates an individual's plea for support, making confidentiality paramount as stated under 34 CFR 361.49. From capturing personal referral information to detailing the nature of the disability and its impact on daily living and employment, the form is comprehensive. It emphasizes the necessity of the applicant's Social Security number for processing, abiding by legislation per IC 4-1-8-1. Moreover, it delves into the realm of an applicant's medical, educational, and employment history, offering a holistic view needed for the customized support plans. Prospective services from either the Bureau of Developmental Disabilities Services or Vocational Rehabilitation Services hinge on the thorough completion of this form. It culminates in the consent for information release, emphasizing the voluntary nature of this permission which remains valid throughout the period of seeking or receiving services. Thus, completing the State Form 10057 is a step toward harnessing the concerted efforts of various agencies to aid in an individual’s rehabilitation or habilitation, marking the beginning of a meticulously crafted journey towards empowerment and independence.
| Question | Answer |
|---|---|
| Form Name | State Form 10057 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ddars_referral_ application ddars referral and application form |
DDARS REFERRAL AND APPLICATION
State Form 10057 (R4 /
Civil Rights Act of 1964 (P.L.
CONFIDENTIAL per 34 CFR 361.49
DIVISION OF DISABILITY, AGING AND REHABILITATIVE SREVICES
Bureau of Developmental Disabilities Services
Vocational Rehabilitation Services
*Your Social Security number is being requested by this state agency Per IC
PART 1 – REFERRAL INFORMATION
Name (last, first, middle, maiden) |
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Date of referral |
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Address (street and number, city, state) |
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County |
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ZIP code |
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*Social Security number |
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Date of birth (mo., day, yr.) |
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Sex |
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Telephone number |
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Male |
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Female |
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Disability / diagnosis |
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Referral source |
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Telephone number |
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If deaf or |
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No |
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Does the applicant have a driver’s license? |
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Can the applicant use public transportation? |
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No |
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No |
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PART II – APPLICATION/DESCRIPTION
Describe the disability and how it affects the applicant’s daily living skills and specific work tasks. How may the services of these agencies assist in accomplishing the goals of the individual and how it will impact on the family.
Name of Doctors / Hospitals Familiar With Applicant Disability / Diagnosis
Address of Doctors / Hospitals
Date and Type of Last Exam
Describe any medical attention the applicant is now receiving / has received (include medicines, therapies, and counseling)
Name one (1) person who will know the applicant’s address in the event of a move.
Name and Relationship |
Address (street and number, city, state) |
Telephone Number |
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List schools the applicant has attended beginning with the most recent (High School, Trade, Business, etc.) |
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Type of Training |
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Highest Grade |
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Name of School |
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City and State |
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Degree / Certificate |
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Completed and Year |
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List jobs the applicant has had beginning with the most recent. (attach additional sheet if necessary) |
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Name of Employer, |
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Employent |
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City and State |
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Job Title |
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Wages |
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Reason for Leaving |
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From |
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To |
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2. |
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3. |
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4. |
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List work tasks on the jobs identified above. |
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1. |
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2. |
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3. |
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4. |
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List rehabilitation programs or other agencies at which the applicant has previously received services beginning with the most recent.
Facility or Agency’s Name and Address (street and number, city)DateKinds of Services
I have been informed that al information obtained is confidential. I hereby give consent for the release of information related to my physical, mental and social condition by the Division of Disability, Aging and Rehabilitative Services. Such information is to be used only by persons or agencies authorized to help in my habilitation / rehabilitation program. This consent will remain valid as long as I am seeking or receiving services from the agencies. I have received written information concerning my right to appeal certain decisions made by these agencies and their contractors or
vendors and the procedures to be followed in making such an appeal. I hereby apply for services from (check one or both) |
Vocational |
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Rehabilitation Services |
Bureau of Developmental Disabilities Services. |
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Signature of applicant / parent / guardian / advocate
Date signed (mo., day, yr.)
I acknowledge the receipt of Notification of Parent / Client Rights and the opportunity to have these rights explained to me. (for BDDS applicants)
Signature of parent / guardian or advocate
Date signed (mo., day, yr.)