Enabling access for all individuals.

SERVICE REFERRAL ONLINE FORM

California Department of Rehabilitation counselors can submit this form to initiate assistive technology services for their consumers. Southern California service area: Los Angeles, Orange, Inland Empire (Riverside & San Bernardino), and San Diego.

REFERRING COUNSELOR INFORMATION

Referring Counselor

First Name

Last Name

Counselor Telephone

(###)

###

####

Counselor Email Address

DoR District Office

SERVICE

Primary Service

Choose the service for your consumer.

Assistive Technology Eval for Young Adult (School, 504, IEP)

Workplace Assessment for Accommodations

Assistive Technology Assessment

Hardware or Software Training

Technology Troubleshoot/Repair

CONSUMER INFORMATION

Consumer Name

First Name

Last Name

Consumer Telephone

(###)

###

####

Consumer Service Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Counselor Notes

Provide additional detail if required.

Statetek Free Travel Radius.png — Statetek 50 Mile Free Travel Radius

If the consumer's service location is more than 50 miles from 7056 Archibald St, STE 102-101 Eastvale CA 92880:
A set of roundtrip mileage is required for every three hours of service authorized.
E.g. Consumer is in Palm Springs and 9 hours of service authorized, include roundtrip mileage cost for three separate visits.