Missouri Vocational Rehabilitation to ACCT Referral Form

Missouri Vocational Rehabilitation Referral Form to the ACCT Program

"*" indicates required fields

Missouri 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 to the portal.

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 (NOT CRP VENDOR) Vendor #: 44055204504 Procedure Code: 140141900 Fee: $555.00 (Fee: $675 if team travels to Warrensburg-Sedalia-St. Joseph areas).

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