GOVERNMENT OF

THE VIRGIN ISLANDS

DEPARTMENT OF HUMAN SERVICES

VOCATIONAL REHABILITATION PROGRAM

DIVISION DISABILITIES & REHABILITATION SERVICES



3011 Golden Rock C’sted Knud Hansen Complex

Croix, V.1. 00820-4355 1303 Hospital Ground, STE. 1

(Tel.) 340-773-2323 St. Thomas, V.I. 00802-6722

(Fax) 340-773-3641 Referral Information (Tel.) 340-774-0930



(Fax) 340-774-7773



[_] Vocational Rehabilitation

[_] Independent Living

C] Pre-Employment Transition Services



Name: Sex“ Social Security No.



Date of Birth _ Age Place of Birth



Citizenship Status | Alien Regis. No. Occup.



Home Address Mailing Address



Tel. No. Work Home Cell Email



Person to notify of emergency



Referred By Date of referral



Statement of Disability



Type of service requesting



Social Security Beneficiary No_ ~=+Yes____ Workman’s Compensation

Medical Assistance No —S—- Yes__—‘« Card Number



Health Insurance No_—s- Yes____ Name of Company (ies)

Public Assistance Nos Yes___ Type of Service



Name & Address of client Physician



Name & Address of referral source or organization



* Professional personnel referring client, when possible please obtain release from client or guardian attach

pertinent medical, psychiatric. psychological, or education information.



FOR VOCATIONAL REHABILITATION USE ONLY



Referral Taken by: Assigned to: Date:



Note to counselor: As a professional courtesy to doctors, professional service workers, agencies or organization making

referral, please fill out and send to “Report Back to Referral Source” form at the end of the evaluation process. DRS-VR 05-2017



Referral Form