Free 46206.PDF - Indiana

REFERRAL FOR SERVICES FOR THE BLIND AND VISUALLY IMPAIRED
State Form 46206 (R / 11-02) / BVIS 0002

INDICATE SERVICE(S) REQUESTED: BOSMA REHABILITATION CENTER ITINERANT REHABILITATION TEACHING PERSONAL ADJUSTMENT INTERVIEW PERSONAL ADJUSTMENT TRAINING LIGHTING ASSESSMENT LOW VISION FOLLOW-UP FACILITY TRAINING FOLLOW-UP ADAPTIVE TECHNOLOGY LAB COMPUTER SKILLS TRAINING COMPUTER/SOFTWARE ASSESSMENT (RECOMMENDATION ONLY) WORKSITE ASSESSMENT (PLEASE PROVIDE ADDRESS AND TELEPHONE NUMBER IN THE COMMENT SECTION) CAREER INTEREST INDICATOR ADMINISTRATION EMPLOYER CONSULTATION BUSINESS ENTERPRISE PROGRAM (PLEASE INCLUDE COMPLETED BEP REFERRAL INFORMATION FORM) NAME OF CLIENT ADDRESS: (NUMBER AND STREET, CITY, STATE, ZIP CODE) AGE

HOME TELEPHONE NUMBER WORK DAY/HOURS: DATE OF BIRTH DISABILITY(IES): PRIMARY: OTHER: VISUAL ACUITY CASE STATUS VOCATIONAL GOAL/INTERESTS:

WORK TELEPHONE NUMBER

SOCIAL SECURITY NUMBER *

SECONDARY:

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DATE AVAILABLE TO BEGIN PROGRAMMING: SPECIAL NEEDS OR LIMITATIONS OF THIS CLIENT:

COMMENTS:

ATTACHMENT (PERTINENT TO SERVICE(S) REQUESTED): VR REFERRAL AND APPLICATION VR CERTIFICATION INDIVIDUAL PLAN FOR EMPLOYMENT (IPE) GENERAL MEDICAL EXAM OPHTHALMOLOGICAL EXAM OTOLOGICAL EXAM PSYCHOLOGICAL EXAM PERSONAL ADJUSTMENT EVALUATION AND / OR TRAINING REPORTS ORIENTATION AND MOBILITY EVALUATION AND / OR TRAINING REPORTS COMMUNITY EMPLOYMENT ASSESSMENT OTHER EVALUATION AND / OR TRAINING REPORTS REFERRED BY: SIGNATURE TELEPHONE NUMBER DATE

* The request for your Social Security number is VOLUNTARY and you will not be penalized for not supplying it. This completed form is CONFIDENTIAL according to the Rehabilitation Act as amended 1973.

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BUSINESS ENTERPRISE REFERRAL
BUSINESS ENTERPRISE PROGRAM (BEP) REFERRAL INFORMATION LEGALLY BLIND: YES NO PROOF OF CITIZENSHIP: SUBMIT COPY OF ANY OF THE FOLLOWING: Social Security Card / Benefit Notice, Medicaid / Medicare Card, Drivers License, Birth Certificate, Voters Registration Card or other. HIGH SCHOOL DIPLOMA? YES NO MATH ABILITY: Above 8th Grade Level Below 8th Grade Level BUSINESS EXPERIENCE / TRAINING:

KEYBOARDING SKILLS? YES NO

GOOD FAIR POOR INDEPENDENT LIVING SKILLS: ORIENTATION AND MOBILITY SKILLS: GOOD FAIR POOR GOOD FAIR POOR PREFERRED MODE OF COMMUNICATION: COMMUNICATION SKILLS: BRAILLE LARGE PRINT TAPE DISK GOOD FAIR POOR OTHER MEDICAL LIMITATIONS:

INTERPERSONAL SKILLS: GOOD FAIR POOR WHY DO YOU FEEL THIS INDIVIDIUAL IS A GOOD CANDIDATE FOR SELF-EMPLOYMENT AND HAS THE POTENTIAL TO OPERATE A SMALL BUSINESS SUCCESSFULLY?

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