1.
Name:
2.
Date this plan begins
Date this plan ends:
3.
My disability causes the following employment barriers:
4.
I have other employment barriers not related to my disability including:
5.
Description of the job or other work setting I seek:
6.
These are my personal qualities, skills, abilities and strengths that
support this goal:
7.
Here are my solutions to overcoming the barriers listed above:
8.
This is how I want my rehabilitation counselor to be involved with me
throughout this plan:
Encourage
me throughout this plan.
Help
me work out any problems that might come up.
Provide
on-going guidance and counseling.
Other:
9.
These are the services I need to overcome my employment barriers so I can
work:
a.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
b.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
c.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
List
additional services needed on the Supplemental Sheet.
10.This
is how I will know if I am making progress toward my job goal:
11.
These are the services I might need at the end of this plan so I can remain
employed:
Having
developed this plan, I agree to:
·
Complete
it to the best of my ability.
·
Notify
my counselor immediately if I need to change this plan.
·
Review
this plan with my DVR counselor at least once a year to decide whether I need
any changes made. This is in addition to meeting regularly to review my
progress.
·
Go
to work at the completion of this plan.
·
Apply
for other resources through the following organizations to help pay for these
services:
·
These
other responsibilities:
The
Division of Vocational Rehabilitation provided me with information about the
following:
·
My
right to choose how to develop this plan.
·
Availability
of assistance in developing this plan.
·
An
explanation of the agency’s guidelines & criteria regarding who pays for
the services I need.
·
Evaluating
my ability to help pay for these services.
·
Helping
me understand my rights as a participant and how to resolve any problems if they
arise.
·
The
Client Assistance Program and how I can contact their representative.
·
My
right to appeal any action made by D.V.R. with which I disagree. I understand I
must make my dissatisfaction known to D.V.R. within 30 days of the action in
question.
13.
AGREEMENT AND AUTHORIZATION OF SERVICES
I picked the above employment goal, the services I need and the individuals or organizations who will provide these to me. By signing this plan, I intend to go to work. I authorize the Division of Vocational Rehabilitation to proceed with these services, as funds become available.
Participant’s
Signature
date
Guardian
or Representative’s Signature as needed
date
14.
Agency’s Acceptance of Plan
Qualified
Rehabilitation Counselor’s Signature
date
Regional
Manager’s Signature as needed
date
15.
PARTNER AGENCY AGREEMENT:
Signature
of representative
date
Name
of partner agency:
Name:
In
addition to the services listed above, I also need the following services:
d.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
e.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
f.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends:
g.
Service:
Name
of Service provider chosen:
How
I chose this person or organization:
Cost
of service or product:
Who
pays for it?
Amount
D.V.R. pays: $
Date
service begins: Date
service ends: