Vocational Service Referral

Employment & Educational Services

This form will enable E&E Consulting Solutions to better identify your needs, please complete the form below:

Name *

First

Last

Email *

Gender *

Birthdate *

MM/DD/YYYYY

Age *

Last 4 of SSN# *

Client Expressed Vocational Goals *

Disability: Primary *

Disability: Additional *

Client Mailing Address *

Telephone *

Alternate Contact Full Name *

Alternate Contact Telephone *

Client Relationship to Alternate Contact *

Highest Level of Education *

Please indicate if you have some college

Are you currently in high school? *

If Yes, please indicate school *

If No, indicated with N/A

School's Full Address *

Career Services Teacher Name & Contact Number *

SERVICE(S) REQUESTED: (CHECK ALL THAT APPLY) *

Referring Counselor's Comment (s) *

Referring Counselors Name *

First

Last

Email *

Phone *

Unit # and Office Location *

Address *

Signature *

Date *

Website

Appointed to Georgia Governor Brian Kemp’s State Rehabilitation Council, 2019
Certified Rehabilitation Counselor since 2006
Experienced in serving individuals with disabilities in state and federal rehabilitation services and higher education
Advocated for improvements to paratransit services in metro Atlanta
Advocated with Fulton County Library Services and University of System of Georgia institutions to improve access to assistive technology for students with disabilities
Featured presenter at Georgia Association on Higher Education and Disability annual conference, 2019

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