Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Workbook
Appendix A: Sample Referral Form

Sample Employment Program Referral

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Date referral received: ______________________________________________

Assigned to: ______________________________________________________

First meeting with employment specialist: yes_____ (date ________________)

Employment Plan completed: yes______ (date _________________________)

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Client’s Name: ____________________________________________________

Date of Referral: __________________________________________________

Referral Source: __________________________________________________

Client ID #: ____________________ Telephon: e_______________________

Medications and side affects, if any, that might interfere with work such as shaking, memory impairment, drowsiness, etc.:

________________________________________________________________

________________________________________________________________

Substance Use: (substances, current use)

________________________________________________________________

________________________________________________________________

Job suggestions and recommendations for work environments:

________________________________________________________________

________________________________________________________________

Criminal history(if any):

________________________________________________________________

________________________________________________________________

Please include any information you feel would be helpful in assisting this individual in reaching his/her employment goals:

________________________________________________________________

________________________________________________________________

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