Goodwill Logo GOODWILL INDUSTRIES OF MID-MICHIGAN REFERRAL FORM
IDENTIFYING INFORMATION

Consumer's Name
 
First                                        Last

Consumer's Address

Street Address

Address Line 2
    
City                                                                            State

Zip/Postal Code

Consumer's Phone
- -
(###)          ###                  ####

Consumer's Email
@ 

Parent's or Guardian's Name
 
First                                                    Last

Relationship to Consumer
Parent's or Guardian's Phone
- -
(###)          ###                  ####
MEDICAL

Primary Disability:    

Secondary Disability:    

Limitations/Pre-Existing Conditions/Considerations/Restrictions:
PROGRAM AND REHABILITATION HISTORY


Other Agencies Involved (including name of counselor:


Previous Programs (including dates):


Previous Programs at Goodwill Industries (including dates):
PREVIOUS EMPLOYMENT

First Company Name:  

Job Title:  

From:   /  /
               MM                   DD                  YYYY

To:   /  /
               MM                   DD                  YYYY
Reason for Leaving:  


Second Company Name:  

Job Title:  

From:   /  /
               MM                   DD                  YYYY

To:   /  /
               MM                   DD                  YYYY
Reason for Leaving:  


SUPPLEMENTAL INFORMATION
Other pertinent data which may assist in services (criminal background, family issues, pending appointments, transportation difficulties, child care, etc.)




SERVICE REFERRAL INFORMATION (CHECK ALL THAT APPLY)
Employee Development
Community Based Vocational Assessment
Community Employment Services
Job Seeking Skills
Job Development
Employment Retention/Follow-Up
Job Coaching/Job Shadowing
Job Club
Microenterprise Development
Supported Employment
Maintenance Wage
Meal Ticket
Computer Training
School-to-Work Transition
Other:  

Please list specific program requests or concerns:
TYPE OF WORK ASSIGNMENT DESIRED (Complete this section only if referring for assessment)
Assignment to one job station to determine learning curve, maximum productivity, stamina, and ability to stay on task.

Varied work assignments to determine baseline productivity on a variety of tasks, client interests, flexibility, etc.


Name of Referring Counselor:          Today's Date:   /  /
                                                                                                                                                                           MM                   DD                  YYYY

Referring Agency:  
FOR PRIVATE INSURANCE ONLY - PLEASE COMPLETE THE SECTION BELOW
Carrier Name:    

Address:            

Contact Person: 

Click on the "Submit" button below to send this form to the Workforce Development Department at Goodwill Industries of Mid-Michigan, Inc.  Please be assured that all information is confidential and is used only the the Workforce Development staff at Goodwill Industries of Mid-Michigan, Inc.