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Referral form for Extended Employment Services (EES)
From:
IDVR Region:
Date:

(VRC making referral)

Customer's Name:
Street Address, Apt:
City, State, Zip:
Phone:
Email address (if applicable):
PARTICIPANT NUMBER:
Gender:

MALE

DOB:
FEMALE

Does Customer have a Guardian:

YES

NO

Guardian's Name:
Street Address, Apt:
City, State, Zip:
Phone:
Email address (if applicable):
DD Waivered:
YES
NO
A&D Waivered:
YES
Medicaid state plans are not waivered, and do not cover CSE
TSC Name (if applicable):

Company:

Extended Employment Eligibility Category:

NO

Phone:
DD

MH

SLD

TBI

Summary of Eligibility Medical Documentation (This should include diagnosis used for eligibility
determination, date of determination, and name of medical professional making the determination:

Summary of Eligibility Vocational Documentation This should include the barriers to
employment the customer has because of the disabling condition, a summary of vocational services and
their results in determining the need for long term vocational services:

Service Requested:
Work Services
CSE/EES
Electronic submission of signed EES Rights and Responsibilities form due upon time of referral.
EES Contact Information: Steve Achabal

Phone: 208-334-3390
Email: steve.achabal@vr.idaho.gov

Revision Updated 07-15-2016

IDVR 650 W. State Street #150 Boise, ID 83720


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