KASVI Referral Form

Participant Information - ** indicates required fields

Participant's Name^**

Currently enrolled in High School?^**

If Yes, enter Graduation Year^**

Participant's Contact Number

Members of Participant's Household

Referral Date^**

Date of Birth^**

Age^**

Street Address^**

Apartment/Unit #

City^**

State^**

Zip Code^**

Guardian Information

Primary Guardian Name

Primary Contact Number

Secondary Contact Number

Employment/Vocational Information - ** indicates required fields

Currently Employed?^**

If Yes, where:

If Yes, how many hours per week:

Currently Receiving Vocational Services?^**

If Yes, from whom:

Support currently needed to maintain employment?^**

Referral Information - ** indicates required fields

Name of Referring Person^**

Title/Position

School District

Agency

Telephone Number^**

E-mail Address^**

Services Requested - Check all that apply

Career Planning

Career planning is a service that provides support to the participant to identify a career direction; develop a plan for post-secondary education and/or plan for achieving job placement in competitive, integrated employment at or above the minimum wage.

Job Finding

Job Finding is a service that provides assistance to the participant in developing job skills and securing competitive, integrated employment that fits the participant's needs and preferences as well as the employer's needs. Job support consists of assistance with learning job tasks, periodic follow-up and ongoing support with individuals and their employers.

Supported Employment

Supported Employment is a service that provides assistance to the participant at their job site for the maintenance of competitive employment. Supported Employment consists of increasing training and supervision needed to maintain and sustain employment.

In-home and Community Support

Home and community-based services are provided to individuals who need assistance in the acquisition, retention, or improvement of skills related to living and working in the community.

Review of Eligibility Requirements

Must be 12–35 years of age at time of enrollment
Be an individual identified as having Autism
- Special Education identification and documentation as a student with Autism and/or medical diagnosis of Autism Spectrum Disorder
Must reside in Lehigh County during application and while receiving services
Must be willing to provide follow up data after 6 months of exiting the program
Capacity to perform activities of daily living (i.e. bathing, eating, using the toilet)
Not exhibit levels of extremely problematic behaviors that present a danger to self, others or threat to property or require direct supervision to ensure health and safety

In order to receive the maximum benefit of services, the following criteria must be met:

Flexible schedule to accommodate up to six hours of services a week
Active parental/family engagement
Collaboration with IEP team when applicable
Minimum four month commitment of individual and parent
Current/future goals to obtain/maintain competitive employment and/or post-secondary education
Not currently enrolled in a program which would result in a duplication of services

Participant meets eligibility requirements^**

If no, please specify in the space provided below. Information provided will be taken into account when determining enrollment.

Please provide additional background information, as well as future aspirations of the young adult.

Please review the above information prior to submitting.
If correct, submit the information using the button below.

KASVI Referral Form

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Keystone Human Services KASVI Referral Form

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KASVI Referral Form