Forms

Please note, if you are seeking career counseling or mental health services, please use the Contact Form located on our Contact Us page.

WCC VR-06

Please complete this required form if you are referring a Maryland WCC case.

MalcolmDubato Provider #165

Contact us for staff practitioner numbers, or refer to the WCC’s Listing of Registered Vocational Rehabilitation Counselors.

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Referral Form - Workers' Compensation Cases

Services Requested (check all that apply)*
- Vocational assessment only
- Vocational rehabilitation (including assessment)
- Case management
- Medical case management
- Labor market survey
- Life care plan
- Vocational expert opinion report
Employer/Insurer Information
Name
First Last
Title
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Fax
Email
Claim #
Claimant Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Date of Birth
MM slash DD slash YYYY
Last four digits of Social Security Number
Employer
Job Title
Date of Incident
MM slash DD slash YYYY
Body Part/Diagnosis
AWW
TTD Rate
WCC/OWC#
Claimant Attorney Information
Name
First Last
Firm
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Fax
Email
Paralegal
Defense Attorney Information
Name
First Last
Firm
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Fax
Email
Paralegal

Referral Form - Personal Injury/General Liability Cases

Services Requested (check all that apply):*
- Labor market survey
- Life care plan
- Vocational expert opinion report
Case Information
Plaintiff Name
First Last
Defendant Name
First Last
Case Name
Case Number
Court
Date of Incident
MM slash DD slash YYYY
If Discovery deadline is known, please enter
MM slash DD slash YYYY
Referral Source Information
Referral Source
- Defense attorney
- Plaintiff attorney
Name
First Last
Firm
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Fax
Email
Paralegal
Billing Information
Billing Name
First Last
Company to Bill
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Billing Phone
Billing Fax
Billing Email

Forms & Resources For Vocational Clients

Sample Employment Application

Please complete this sample employment application and submit it to your vocational consultant for review.

Sample Application

Independent Job Search Form

Please submit your IJS form to your vocational consultant before the close of business [5:00 p.m.] on your assigned due date. You may complete the form below or the paper copies provided to you.

IJS Form