REFERRAL

THIS IS NOT AN APPLICATION FOR SERVICES

1. Personal

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

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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.

* (Limit 32 Characters)
(Optional. Not the same as Home Address Above!)


(Click to add a Mailing Address)

(Limit 32 Characters)
(Optional. Not the same as Mailing Address Above!)

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

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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!!)

(Limit 50 Characters)


Transition Student Info

   Yes

This Section is for School or DVR Staff Only

  


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

If available, please attach the following documents. (Not Mandatory)
Accepted file types include PDF, DOC, DOCS, 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

   Yes

Supported Employment Attachment Info

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

Release of Information


Individual Service Plan (Current ISP)


Freedom of Choice Form


Level Of Care Form