State Form 10057 – Fill Out and Use This PDF

PART 1 – REFERRAL INFORMATION

Name (last, first, middle, maiden)

Date of referral

(mo., day, yr.)

Address (street and number, city, state)

County

ZIP code

*Social Security number

Date of birth (mo., day, yr.)

Sex

Telephone number

Male

Female

(

)

Disability / diagnosis

Referral source

Telephone number

If deaf or non-English speaking, is an interpreter needed

(

)

Yes

No

Does the applicant have a driver’s license?

Can the applicant use public transportation?

Yes

No

Yes

No

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.

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

						(		)
List schools the applicant has attended beginning with the most recent (High School, Trade, Business, etc.)
							Type of Training		Highest Grade
Name of School			City and State				Degree / Certificate		Completed and Year
List jobs the applicant has had beginning with the most recent. (attach additional sheet if necessary)
Name of Employer,									Employent
City and State			Job Title		Wages		Reason for Leaving		From		To
1.
2.
3.
4.
List work tasks on the jobs identified above.
1.
2.
3.
4.

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
Rehabilitation Services	Bureau of Developmental Disabilities Services.

I acknowledge the receipt of Notification of Parent / Client Rights and the opportunity to have these rights explained to me. (for BDDS applicants)