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Professional Disclosure Form - Public Sector Example
The purpose of public vocational rehabilitation is to assist eligible persons with disabilities in achieving an employment outcome. This outcome may be returning to your former job or obtaining a job in a new field. You and your counselor will work together to find a job that you are physically and mentally able to do that is as close as possible to your vocational goals.
You will be working with a person who is a qualified rehabilitation counselor (RC) or is being supervised by one. You will be assigned a RC. If you are not satisfied at any time, you can inform your RC, his/her supervisor, or the state agency that handles such complaints. If you feel the RC has acted in an unethical manner, you should contact the Commission on Rehabilitation Counselor Certification.
To be eligible for vocational rehabilitation services, you may first be asked to take part in an evaluation. As much as possible, your RC will use information already available in your file. However, your RC may need you to sign a release of information form so that more information can be gathered. Additional tests, exams, or evaluations may be necessary to determine if you qualify for vocational rehabilitation services.
If you are eligible for vocational rehabilitation services, you and your RC will jointly develop an Individual Plan of Employment (IPE). The IPE spells out your vocational goals and the services that will be provided in order to help you reach those goals. It is important that you exercise your consumer choice by actively participating in the development of the IPE. Some of the services that may become a part of the IPE include the items listed below. Your RC will explain each service to you.
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Evaluation for vocational rehabilitation needs |
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Physical restoration |
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Counseling and guidance |
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Supported employment |
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Educational training |
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Assistive technology, services, and equipment |
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Job development and placement |
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Employment retention and follow-up services |
The types of services provided will depend on your particular needs. You and your RC are expected to work together to identify the comprehensive services that you will need. The timeframe of your IPE depends upon your goals and your progress. Your IPE can be reviewed and changed by you and your RC as appropriate.
One very important part of your relationship with your RC is confidentiality. Personal information related to your rehabilitation services may be recorded in your file. This information will be kept private except as follows:
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If you have signed a release of information form that allows information to be shared. That form will state who receives what information. While your signature is voluntary, you need to be aware that your decision not to sign means that information cannot be shared with other providers. Thus, it may impact the implementation of your IPE.
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If your RC 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 RC 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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If your RC 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. |
It is important to remember that the goal of the RC is to help you secure a satisfactory job and that services must be related to that goal. It is also important to know that the RC will, at all times, try to act in your best interest and protect you from unnecessary risk.
Before signing this form, your RC will review the following topics with you.
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The RC’s roles and responsibilities |
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Your roles and responsibilities |
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The RC’s approach or method |
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Legal issues affecting services |
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Confidentiality |
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Creating and using the IPE |
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Goals and types of services provided |
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Types of services not provided |
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Risks and benefits associated with services |
By signing this form, I attest that I have discussed the aforementioned topics with my RC and
that I understand the information discussed as well as the information contained within this
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Signature of Client |
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Date |
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Printed Name of Client |
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Signature of Legal Guardian |
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Date |
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Printed Name of Legal Guardian |
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Signature of RC |
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Date |
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Printed Name of RC |
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Commission on Rehabilitation Counselor Certification. (2006). Professional Disclosure Form – Public Sector Example. 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 public sector. The form must be reviewed for applicability to each particular case and appropriate modifications must be made.
Developed 8/02 – Revised 8/06
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