FLORIDA DEPARTMENT OF EDUCATION

Division of Vocational Rehabilitation

2007-2008 ALERT FORM

In order to assist with the timeliness of the intake process please complete the following prior to
referring a student to Vocational Rehabilitation

• Please complete this form in its entirety.

• Please notify parent/guardian that student information is being released to VR to assist with transition services if the
student is a minor. Please include a signed Consent for Mutual Exchange of Information or similar signed consent to
release student information to VR.
• Please attach any relevant records that you may have including transcripts, recent psychological evaluation or work
evaluation.

STUDENT NAME : ASHLEY GRATES SSN: 590-23-8140

DOB: APRIL 24, 1992 GRADE: 12 SEX: FEMALE RACE : WHITE
MAILING ADDRESS: 7108 MAIDSTONE CT CITY: NEW PORT RICHEY, FLORIDA ZIP: 34653
HOME # (727) 372-6072 CELL # EMAIL ADDRESS

PARENT/GUARDIAN NAME PHONE WORK PHONE

PARENT/GUARDIAN NAME PHONE WORK PHONE
ARE THERE ANY LANGUAGE BARRIERS? YES NO X EXPLAIN:

__EXCEPTIONALITIES__
(Please check all that apply)
Emotional Impairment Physical Impairment Speech Impairment
Specific Learning Disabilities X EMH TMH Autistic
Blind/Visual Impairment Deaf/Hearing Impairment Other Health Impairment
Other (explain)
Other agencies involved

How will this student’s disability/impairment be a problem in obtaining and keeping a job?
Ashley has problems concentrating and staying focused to task at hand. She is interested in the Military.

SCHOOL/ AGENCY INFORMATION

School/Agency Name Referred By

Type of Diploma Special __ Regular _ Other ______ IEP _______ 504 ______ FAPE 22

(Office use only)

Referral status: ____No response to letter/phone call _____ Applied for services _____ Declined services ______ Referred to other agency

4440 Grand Boulevard, New Port Richey 34652

(727) 816-1714 phone; (727) 816-1754 fax
Florida Relay Service: 1-800-955-8771 (TTY) * 1-800—9558770 (voice) * www.fldoe.org