Vocational Support Referral

Today's Date*

Applicant Name:*

Date of Birth*

Applicant identifies as:*

(You can click the text box below to give a description if you prefer.)

Male
Female

Education

Some high school
High school diploma or GED
Vocational training or certificate
Some college
College (or Graduate) degree

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Who is making this referral?

Agency / organization
Parent / guardian
Self

Name of referring agency/organization*

Agency phone number*

Name of person making this referral*

First Last

Parent/Guardian Name*

First Last

Parent/Guardian phone number*

Applicant phone number

Application Questions

What is the primary reason for this referral?*

What would you like to achieve in the program?*

(e.g. "find a job" or "earn more money")

Please describe your recent employment history (if any):*

(or put "none" if first-time job seeker)

Do you live independently? If not, do you plan to?*

How do you like to learn new things?*

(e.g. hands-on, observing others, etc.)

Is there anything else you can tell us that would help us provide vocational services to you?*

(e.g., criminal history, mental health, addiction, gaps in employment, etc)?

Do you have access to any of the following for regular transportation?*

(Select all that apply)

I can drive, walk, or take the bus.
A friend or family member can drive me.
I do NOT have reliable transportation of any kind.

Do you currently have a disability?*

Yes
No

Not Sure? Learn More to see if this applies to you.

Which of these best describes your primary disability?*

This means the disability that interferes the MOST with your ability to function at work, school, or home.

Blind or vision-impaired
Deaf or hearing-impaired
Physical disability
Intellectual or developmental disability/delay
Social/emotional disability
None

Not Sure? Learn More to see if this applies to you.

Which of these best describes your secondary disability?*

Blind or vision-impaired
Deaf or hearing-impaired
Physical disability
Intellectual or developmental disability/delay
Social/emotional disability
None

Not Sure? Learn More to see if this applies to you.

Have you previously received services from the Kentucky OVR (Office of Vocational Rehabiliation)*

Yes
No

On a scale of 1–10 (10 being highest) rate your level of:

Academic performance

Social skills

(Forming and maintaining friendships, meeting new people, etc.)

Family support

Communication skills

(such as verbal or written skills, conflict management)

Confidence about job/career plans

Daily Living Skills

(personal care/hygiene, cooking, shopping, cleaning, etc.)

Independence

(e.g. waking up on time or making a phone call on your own)

Phone

This field is for validation purposes and should be left unchanged.