Supported Employment Referral Supported Employment Location(Required)Baltimore City OfficeLower Shore OfficeMid Shore OfficeYour emailDate(Required) MM slash DD slash YYYY Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY AgeRaceSex at BirthGender Identity and Preferred PronounsHome Address(Required) Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home/Cell(Required)Medicaid Number(Required)SSNCurrently enrolled in SSI/SSDI Yes No Pending Other EntitlementsICD-10 INFORMATIONPrimary Behavioral Diagnosis(Required)Additional Behavioral DiagnosisPrimary Medical DiagnosisHas the participant been in active mental health treatment?(Required) Yes No Treating Therapist Name/Credential(Required)Phone Number of Treating Therapist(Required)Name of PsychiatristPhone number of PsychiatristHas medication been prescribed to support mental health?(Required) Yes No If yes to medication, name of prescriber, medication, dosage, and frequency.GOALS OF VOCATIONAL REHABILITATION SERVICESDescribe Goals Below(Required)EMPLOYMENT HISTORYPlease describe previous work experience below(Required)RISK ASSESSMENTAre there any risks for aggressive behavior, suicide, or homicide?(Required) Yes No If yes, explainHistory of in-patient or at risk of in-patient hospitalizations?(Required) Yes No If yes, explainCurrently on Conditional Release, Parole, or Probation(Required) Yes No If yes, explainSupported Employment serices/referral has been explained to participant or parent/guardian of participant and they are in agreement.(Required) Yes No Referral Source SignatureDate MM slash DD slash YYYY
