NICIA
Access4Jobs
Vocational Referral
A Collaboration of Community Behavioral Health Services & the
Department of Rehabilitation partnered with RAMS Hire-Ability, Citywide
Employment Programs, Caminar Jobs Plus and Positive Resource Center
Thank you for your interest in Vocational and Employment Services.
Client Name
DOB
Primary/Language
:
Address
Ethnicity
Gender
:
Zip
Phone
Email
:
Case Mgr/Therapist ___________________________________________ Email
_________________________________________
Agency
Contact #
What is your Vocational Goal?  Paid Employment  Training/Education
Vocational Interests:
What is your program of interest?
 RAMS Hire-Ability
Assessment Services
Employment/Job Coaching Serv.
Soft Skills Training, IT Training
and Janitorial Training
(If no preferred service, referral will be based on appropriate match)
 Citywide
Assessment Services
Employment Services
Basic Construction Training
 PRC Clerical Training
Clerical Training Program
 Caminar Jobs Plus
Assessment Services
Employment Services
Job Coaching
Citywide can provide employment services for persons solely with mental health needs OR persons with mental
health needs and a criminal justice background/pending legal charge. Is there any criminal history?
Please explain:
Can you provide documentation to work in US?
□Yes
□No
Your response is confidential. If you do not have
documentation, Access4Jobs may still be able to refer you to
vocational services.
I authorize my diagnosis to be released and exchanged by the referring source to the Access4JOBS triage team.
CLIENTS SIGNATURE:
DATE:
CLINICAL SECTION: This section must be completed by a licensed clinician.
Pertinent History / Hospitalizations ________________________________________________________________________________________________
__________________________________________________________________________________________________ ___________________________________
Current Treatment/Medication____________________________________________________________________________________________________
______________
Current mental status (symptoms)
Ability to handle responsibility?
Able to tolerate full day of employment training?
Motivation & cooperation
Ability to accept constructive feedback
Concentration/learning ability
Occupations/situations to avoid
Assaultive/violent history
Frustration tolerance
Judgment
Axis I________________Axis II _________________Axis III _________________Axis IV________________Axis V___________________
Comments:
_
Referred by: (name & credential)
Signature
*Co-Signature: (if applicable)
Signature
Agency/Address
Phone
Date
* Co-signer must have one of these professional credentials: MFT, LCSW, MD, PsyD, or PhD.
(Department of Rehabilitation does not recognize the County Waivered LPHA)
* Please send this completed form by FAX: 888-262-3988 Questions? Please call: Stephen Dempsey, CBHS, 415-255-3664
Rev 7/09, 9/09; 1/10; 6/10, 7/12, 3/13, 6/13, 6/14
This Referral Form is designed to provide quick access and linkage to vocational and employment services
for adults who meet criteria for mental health needs.
CBHS: The vision of Community Behavioral Health Services is to have a welcoming, culturally and linguistically
competent, gender responsive, integrated, comprehensive system of care with timely access to treatment in
which “Any door is the Right Door”. The mission of behavioral health services in the San Francisco Department
of Public Health is to maximize clients’ recovery and wellness for healthy and meaningful lives in their
communities.
DOR: The California Department of Rehabilitation works in partnership with consumers and other
stakeholders to provide services and advocacy resulting in employment, independent living and equality for
individuals with disabilities.
RAMS Hire-Ability is a not-for-profit program that provides culturally competent vocational services to
individuals with behavioral health issues. We strive to provide participant driven, individualized and
meaningful services as part of the Recovery model. Our services are geared towards assisting participants in
obtaining and maintaining meaningful and gainful employment. We provide a full spectrum of vocational
services such as assessment services, soft skills training, occupational skills training services and employment
services. Our Employment Services department utilizes the Individual Placement & Support (IPS) model, an
evidence-based employment model for individuals with significant behavioral health conditions. The
Employment Services department provides employment preparation services, job placement, retention and
job coaching services. We offer services in English, Cantonese, Mandarin, and Tagalog.
Citywide Employment Program assists individuals with behavioral health needs attain competitive employment
and has specialized services for those with a criminal justice history and/or pending legal charge. The
Employment Team is embedded within the larger clinical case management program, and uses the Individual
Placement and Support model of Supported Employment, a well-researched, evidenced-based approach
demonstrating significant results with the mentally ill. The Employment Team provides vocational assessment
and employment services which include: individualized job searching; assistance with criminal record
expungement and education on how to talk to employers about a criminal history; job development; review
of strengths, barriers, goals and objectives; review of previous work experience; assistance with interviewing,
resume building and preparation; basic hygiene and grooming assistance; education around understanding
expectations of employers; interview coaching; and help with understanding how earned income affects
benefits. We offer services in English, Spanish, Russian, and French.
Caminar Jobs Plus fully supports people who want to learn new skills and develop career goals. With job
placement and supportive employment services for people with all types of disabilities, including mental health
disabilities, Jobs Plus works with each individual to find a job and then provides job coaching to ensure
vocational success. The program offers job assessment, vocational training, skills development, and assistance
with pre- and post-job application preparation: resume writing assistance; and interviewing skills. By
developing a wide network of community and business connections, Jobs Plus can make working a reality and
help pave the road to financial success for our participants. We offer services in English, Spanish, Russian, and
Tagalog.
Positive Resource Center is the only employment service provider in the Bay Area that has specifically
developed its program for people who are facing multiple employment barriers including people with mental
health disabilities and/or HIV/AIDS. The PRC Employment Services Program assists clients who want to work in
or gain clerical training or education in the clerical field.
Rev 7/09, 9/09; 1/10; 6/10, 7/12, 3/13, 6/13, 6/14