Kansas Vocational Rehabilitation to ACCT Referral Form

Kansas Vocational Rehabilitation Referral Form to the ACCT Program

"*" indicates required fields

Kansas VR ACCT Referral Form

ATTN: ACCT Admissions, Fax: 816-751-7984, Admissions Phone: 816-751-7748

Client Name*

First Last

Contact Number*

Email*

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Diagnosis & limitations that impact employment goals (please include ALL diagnoses).*

ACCT Service Needs

Please select from list below:*

Communication Device

Adapted Computer Access-Ergonomics-Tools for Reading

Client Is Employed and Needs Assistive Technology/Accommodations to Maintain Employment

Client is Currently in Job Search/Interest or Preparing to Enter Job Search-Needs Assistive Technology/Accommodations to Secure Employment in This Area

Client is Currently in College/Training or Preparing to Enter College/Training and Needs to Explore What Assistive Technology is Available

Evaluation and Set Up/Training for Remote Learning/Remote Employment Needs

Employer/Type of Employment:

College/Training Goal is:

Additional Information/What VRC Wants from ACCT Service, not Already Indicated:

Guardian Information (if applicable)

Name

First Last

Phone Number

Person to Contact to Schedule Appointment (If Other Than Client):

Name

First Last

Phone Number

Counselor Name

Counselor Phone Number

Counselor Email

When Submitting This Referral:

I am submitting the authorization by fax (please fax to 816-751-7984).

I am contacting admissions because I have a question regarding the authorization process (please contact Admissions at 816-751-7748).

Please Provide Additional Information if Needed.

Vendor: Ability KC, Vendor #: 44055204504 Assistive Technology-Comprehensive Functional Evaluation, FEE: $1320

Kansas SRS AT Description

Comprehensive Functional AT Evaluation – assesses how technology can address functional limitations the consumer experiences in achieving employment and may be conducted at multiple onsite locations across all necessary environments. It requires integration of two or more devices to develop the needed assistive technology solution OR evaluation of a complex device solution (i.e., environmental control units, diverse applications of JAWS). Service may be conducted at multiple onsite locations across all necessary environments, including but not limited to home, worksite, and educational/training school settings, as indicated by needs identified during the referral process OR provide hands-on use or demonstration of appropriate assistive technology within necessary environment, including but not limited to consumer’s worksite, home or educational/training school site.

This field is for validation purposes and should be left unchanged.