Professional Disclosure Form - Private Sector Example - Workers’ Comp/LTD

You have been referred by _______ to receive a vocational assessment. Subject to the referral source requirements, a vocational plan may be developed. Such a plan may include, but would not be limited to, recommendations for the following types of services: case management, counseling, job readiness training, and assistance with returning to work.

The length of services will be based upon several factors such as funding, your injuries and abilities, and your progress. The number of visits or sessions will vary on a case-by-case basis.

The goal of vocational rehabilitation assessment is to identify appropriate employment options, if any, for you. If services are provided beyond the initial assessment, the Vocational Rehabilitation Counselor (VRC) will assist you in developing your vocational goal and determining the services needed to achieve your goal. Often, your VRC will involve other professionals on staff to assist him/her and you in reaching your vocational goal. Discussions regarding your case will be held with such individuals and possibly the VRC’s supervisor. It is important that you and your VRC hold similar views of how you will reach those goals. You have a right to review those goals regularly. Any change to your vocational rehabilitation plan is subject to agreement by you, your VRC, and the referral source. For the most successful rehabilitation services, it is important that you actively work with your VRC. Your insurance carrier has requirements on your active participation in services and failure to participate could result in a reduction of your benefits. If a third party (i.e. insurance carrier) is paying for vocational rehabilitation services, your VRC may be subject to limitations in services, which will be explained to you. For further information, contact should be made with the insurance company.

You and your VRC must work jointly to develop a rehabilitation plan for a successful return-to-work and adjustment to disability. If you are represented by an attorney, he/she will be provided with copies of reports generated by your VRC and informed of progress. In the event your attorney does not allow direct communication with you, either by phone or letter, such will be coordinated through their office.

Vocational rehabilitation services will be provided to you or supervised by a Certified Rehabilitation Counselor (CRC). No matter who has hired your VRC, you are the client. Your VRC must provide services that at all times respect your needs and make sure that your needs are addressed within the limits of what your insurer is obligated to provide in your insurance coverage (contract). If you are not satisfied at any time, you should tell your VRC, his or her supervisor, your attorney, the state agency that handles such complaints, and/or the Commission on Rehabilitation Counselor Certification.

One very important part of your relationship with your VRC is confidentiality. Personal information may be discussed and placed in your file. However, your VRC will do his/her best to keep personal information that is not related to your rehabilitation out of your file. During the course of service provision, all records will be kept private except as follows:

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If a third party (i.e. insurance carrier, attorney, etc.) is paying for services, records may be provided to that party. You will be asked to sign a release of information form that tells you in advance who will be receiving your records.
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 If your VRC becomes aware of any legal issues preventing your ability to be employed in
any or all branches of the labor market or to receive other vocational services, he/she will
be required to notify the referral source.
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If your VRC believes you are going to harm or endanger yourself or others, he/she is required to notify the endangered individual(s), the proper authorities and/or officials.
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If your VRC believes you are going to harm or endanger or abuse children or the elderly, he/she must report this to state or local authorities.
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Requests for information from other parties (i.e. doctors, physical therapists, your employer, etc.) involved in your case may occur. If so, you would have to sign a release of information form before your records could be released. That signature is voluntary.
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If your VRC or this agency is sued or court ordered and a properly issued subpoena is received, then information in your file may be released.
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If you are a minor or not your own legal guardian, then the information in your file may be available to your legal guardian or advocate.

There may be some risks involved in the vocational rehabilitation process. Things you are asked to do may be difficult and challenging. It is important to know that no unnecessary difficulties will be placed upon you. All of the activities of your VRC are ultimately taken in your best interest.

Before signing this form, your VRC will review the following topics with you..
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 The VRC’s roles and responsibilities
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 Limitations on what your VRC can do
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 Your roles and responsibilities
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 Legal issues affecting services
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 Confidentiality
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 Frequency and length of service
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 Nature and type of rehabilitation services provided
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 Risks and benefits involved with vocational rehabilitation services
•
 Risks associated with electronic communication
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 Potential of VRC providing testimony in a court setting regarding your case
•
 Records preservation

By signing this form, I attest that I have discussed the aforementioned topics with my VRC and that I understand the information discussed as well as the information contained within this document.

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Signature of Client		 _____________________
Date
_________________________________________________
Printed Name of Client
_________________________________________________
Signature of Legal Guardian		 _____________________
Date
_________________________________________________
Printed Name of Legal Guardian
_________________________________________________
Signature of VRC		 _____________________
Date
_________________________________________________
Printed Name of VRC


RECOMMENDED CITATION

Commission on Rehabilitation Counselor Certification. (2006). Professional Disclosure Form - Private Sector Example – Workers’ Comp/LTD. Retrieved [date] from, http://www.crccertification.com/pages/30code.html

This disclosure form is provided by the Commission on Rehabilitation Counselor Certification (CRCC) as a sample of the content that would be appropriate to include in a disclosure form for the forensic setting. The form must be reviewed for applicability to each particular caseand appropriate modifications must be made.

Developed 8/02 – Revised 8/06