Driving Evaluation and Training Referral Form
NC Division of Vocational Rehabilitation Services

November 21, 2008, 1:15 pm

CLIENT INFORMATION
First Name:
Last Name:
Middle Initial:
   
Address:
City:
State: (ex. NC, SC)
Zip Code: (5 digit)
   
Email Address:
   
Phone Number (home): (No dashes or parentheses)
   
Phone Number (work): (No dashes or parentheses)
   
Phone Number (cell): (No dashes or parentheses)


PRIMARY CONTACT
   

Relationship:
  Name:
  Phone Number:


DIAGNOSIS
Diagnosis:
Impediment to employment/independent living:
Date of birth
Date of onset of diagnosis
Years of driving experience
Years of driving post-diagnosis


MEDICAL INFORMATION
Medications
(list current amount and history):


Corrective lense:


Seizure free for one year:


Spasms:

 



Mobility:



Transfer into Transfer Seatbase
Drive from wheelchair


DRIVING EXPERIENCE
Accidents/violations in last 5 years

 

Previous driver education/evaluation:

 


DRIVER LICENSE INFORMATION
Driver License:


Driver's License/Permit Number
State (ex. NC, SC)
Driver's License/Permit Number
Expiration date
Restrictions


VEHICLE INFORMATION
Do you own a vehicle?


If you own a vehicle, what kind is it? (Year, Make, Model)

If you do not own a vehicle, is there a certain vehicle you are hoping to obtain?

 


If you drive from a wheelchair, what kind?


ADDITIONAL COMMENTS
What else should we know?




** Complete the one (1) area below which applies, and then click "submit" at the bottom of this page**

REFERRING PHYSICIAN / AGENCY
Referring Physician/Agency:
Case Manager/Rehab Engineer:
Referring Physician/Agency Address:
Referring Physician/Agency Phone #:
Physicians DEA #:
Physicians UEIN #:


WORKER'S COMPENSATION
Insurance Plan Name:
Client's Workers Comp. #:
Insured's Policy Group #:
Pre-authorization #:
Send Invoice To:
Email:


VOCATIONAL REHABILITATION / INDEPENDENT LIVING
VR/IL number(s)

Joint case?

Counselor

Name:
Office:
Engineer:
Address:
Phone/FAX:
Email address


SELF REFERRAL
How did you find out about this service?

Physician's Contact Name:
Physician's Contact Address:
Physician's Contact Phone #:


 

 

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