Make a referral

Counselors and agencies can refer participants for supported employment services here. Fill in the form, attach the authorization, and our intake team will follow up.

DARS Supported Employment Services referral

Fields marked * are required. Your answers fill in our referral form, which is sent securely to our intake team.

Referral

Complete this form and attach the authorization and supporting documents.

Referral date

Approved services

Authorized service 1

Authorized service 2 (optional)

Authorized service 3 (optional)

Funding and referral source

Primary funding source

Additional funding source (optional)

Referring agency

Service area / locality

Counselor name

Counselor phone

Counselor email

Authorization / PO # (optional)

Authorized hours / units (optional)

Authorization start date (optional)

Authorization end date (optional)

Consumer information

First name

Middle name (optional)

Last name

Date of birth

Gender (optional)

SSN (optional)

Phone (optional)

Email (optional)

DARS participant ID (optional)

Street address (optional)

City (optional)

State (optional)

ZIP code (optional)

Primary diagnosis / disability (optional)

Secondary diagnosis / disability (optional)

Comments / referral purpose

Referral details (optional)

Referral reason, requested outcome, work history, transportation, supports, and special instructions.

Documents provided with referral

Which documents are you providing? (optional)

Written Authorization / Purchase OrderIndividualized Plan for Employment (IPE)Documentation of DisabilityMedical / Psychological Records (if applicable)Prior Assessment / Employment Service ReportsOther supporting documentation

Attachment (optional)

One file up to 10 MB: PDF, Word, JPG, or PNG. To send several documents, combine them into one PDF.

This form is sent over an encrypted (TLS) connection. Please share only what the referral needs.

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