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HIRED HANDS AND ASSOCIATES

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Employee Partners Form

Date:
Consumer Name:
Case # (If Applicable):
SSN:
Date of Birth:
Address:
Apt. #:
City:
State:
Zip:
Phone Number:
Alt. Phone Number:
Rehabilitation Office:
Rehabilitation Counselor:
Counselor E-mail Address:
Consumer's Primary Disability:
Consumer's Secondary Disability:
Consumer's Vocational Goal:
Services To Provide: Situational Assessments Independant Living Skills
Job Development Job Coaching
Other Questions or Concerns:

 

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