INTAKE and ASSESSMENT REPORT
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Vocational and Educational Services for Individuals with Disabilities (VESID)
Special Education and Vocational Rehabilitation Services
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Consumer:


SS #:


DOB:


Address:





Phone #:


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Description of disability and functional limitations:








Vocational and educational history (including results of academic and other testing, if available):








Health information (including medications):








Attitudinal, behavioral, and environmental factors:








Other concurrent services or treatment:








Rationale for program recommendation (including discussion of alternatives):








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Signed:


Date:

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