DVR Client Referral Application

1. Personal

Enter your information. When completed, Choose the Next Section button to continue.

Referral Date

SSN

- -

SSN is secured by encryption and using a Secure website.

Workforce ID (If known) STARS ID (If known)

Gender *

First Name * Middle

Last Name * Birthdate

Instructions for Entering Addresses and/or Phone Number You can enter either a Home address, Mailing Address, and/or Primary phone. This information is necessary in order for a DVR Staff Member to contact you and to also determine which DVR Office is closest to you for service.

If you only enter a Primary Phone Number, you are required to choose your City of Residence and if Albuquerque, whether you live in the NE, NW, SE, or SW.

Home Address * (Limit 32 Characters)

Home Address 2 (Optional. Not the same as Home Address Above!)

City * State Zip *

Is Mailing Address Different than Home Address? (Click to add a Mailing Address)

Mailing Address (Limit 32 Characters)

Mailing Address 2 (Optional. Not the same as Mailing Address Above!)

City * State Zip *

Primary Phone? Phone Type *

Select City. If City is Albuquerque, Select Area (NE, NW, SE, SW))

City * Area of City *

What is another Phone we can reach you?

If you don't have a phone, please leave a message phone above.

If you would like to get a confirmation email, please enter a valid email below. (ENTER EMAIL ADDRESS ONLY!!)

Email (Limit 50 Characters)

Transition Student Info

Are you attending public, charter, private school or homeschooled, and are between the ages of 14-21? Yes

This Section is for School or DVR Staff Only

Select School for Transition Participant

If your school is NOT listed above, please enter the school name and full address below.

School Name

School Address *

School City * School State School Zip

Transition Student Attachment Information

If available, please attach the following documents. (Not Mandatory)
Accepted file types include PDF, DOC, DOCX, or TXT.
Upload each individually by first browsing to the desired file and then selecting the Upload button for each.

Release of Information

Individual Education Plan (Current IEP)

Diagnostic Evaluation / Re-Evaluation Eligibility Determination

Supported Employment Info/ DD Waiver Wait List

Are you receiving DD Waiver Funds, Mi Via Funds, State General Funds or Intermediate Care Facility (ICF) Funds? Yes

Supported Employment Attachment Info

Release of Information

Individual Service Plan (Current ISP)

Freedom of Choice Form

Level Of Care Form

Required *