Occupational Skills Training
VA Vocational Rehabilitation Referral
2305 SE 82
nd
Ave, Portland OR 97216
Fax (971) 722- 6124 Phone (971) 722-6127
Date ___________________________
STUDENT INFORMATION
Name _______________________________________________ Claim # _______________________
Address ________________________________________________ Phone ______________________
City _____________________________ State _______ Zip _______ Cell ________________________
Email ________________________________________ Date of Birth: __________________________
Vocational Goal/Occupational Area _________________________ Length of Training _____________
Functional Limitations: _______________________________________________________________
__________________________________________________________________________________
Accommodations: _________________________________________________________________
__________________________________________________________________________________
Legal History with Dates: _____________________________________________________________
__________________________________________________________________________________
TRAINING SITE (If site has not been determined, please leave this section blank)
Business/Agency Name _______________________________________________________________
Trainer/POC _______________________________________ Email ____________________________
Address ________________________________________________ Phone ______________________
City _____________________________ State _______ Zip _______ Fax ________________________
Start Date _________________ End Date _________________ Hours/Week ___________________
REFERRAL INFORMATION
Referring Counselor __________________________________________________________________
Address ________________________________________________ Phone ______________________
City _____________________________ State _______ Zip _______ Cell ________________________
Email _____________________________________
Case Manager
(if different from counselor) ________________________ Phone ______________________
Documents Included with Referral: 1905 (if site determined only) PCC Release Resume
Other Documents __________________________________________________________________
