Sample Form DR387 "Supported Employment - Notice of Transition to Extended Services" - California

What Is Form DR387?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DR387 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Sample Form DR387 "Supported Employment - Notice of Transition to Extended Services" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT – NOTICE OF TRANSITION TO EXTENDED SERVICES
DR387 (Rev. 02/08)
Extended Service Provider (ESP) Name & Address:
SEP#:
Date:
999
12/10/2008
Independent Opportunity Support Center
Consumer:
12345 Independence Boulevard
John Jacob Jingleheimer-Schmidt
Funkytown, CA 91233
Date of Birth:
Attn: Melani LeClerc
2/29/1978
Source of Extended Services - Contact Information:
DOR Counselor:
(i.e., regional center service coordinator)
Alexandra Hamilton
Yolocal Regional Center
DOR District:
76 Extension Court
Greater Los Angeles
Longford, CA 90020
UCI #:
Individual
1234567
Group
Effective VR Transition Date:
1/1/2009
DOR funding for supported employment services for the above named consumer will
be discontinued effective on the transition date (the first day of the month after the
stabilization criteria have been met and the source of extended services has been
notified in time for services to be authorized).
Extended services will be provided by the Extended Service Provider named above
after the effective date.
The attached monthly job coach reports confirm that the consumer is stable and ready
to transition to extended services. (Documentation may include the DR384 -
Supported Employment - Monthly Job Coach Reports). These reports can be used to
determine extended services needed. Comments:
The consumer has been receiving 20 hours per month of job coaching
VR Closure: The consumer will be (a) monitored for a minimum of 60 days after the
transition date above to determine whether s/he needs any additional VR services and
(b) closed by DOR thereafter as appropriate.
DOR Counselor Signature:
Email Address:
Phone Number:
Date Signed:
ahamilto
213-736-3904
12/10/2008
@dor.ca.gov
Distribution:
DOR Record of Services
DOR District Office
Regional Ctr. (or other funding source)
Extended Service Provider
SE Service Provider (if different from ESP)
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
SUPPORTED EMPLOYMENT – NOTICE OF TRANSITION TO EXTENDED SERVICES
DR387 (Rev. 02/08)
Extended Service Provider (ESP) Name & Address:
SEP#:
Date:
999
12/10/2008
Independent Opportunity Support Center
Consumer:
12345 Independence Boulevard
John Jacob Jingleheimer-Schmidt
Funkytown, CA 91233
Date of Birth:
Attn: Melani LeClerc
2/29/1978
Source of Extended Services - Contact Information:
DOR Counselor:
(i.e., regional center service coordinator)
Alexandra Hamilton
Yolocal Regional Center
DOR District:
76 Extension Court
Greater Los Angeles
Longford, CA 90020
UCI #:
Individual
1234567
Group
Effective VR Transition Date:
1/1/2009
DOR funding for supported employment services for the above named consumer will
be discontinued effective on the transition date (the first day of the month after the
stabilization criteria have been met and the source of extended services has been
notified in time for services to be authorized).
Extended services will be provided by the Extended Service Provider named above
after the effective date.
The attached monthly job coach reports confirm that the consumer is stable and ready
to transition to extended services. (Documentation may include the DR384 -
Supported Employment - Monthly Job Coach Reports). These reports can be used to
determine extended services needed. Comments:
The consumer has been receiving 20 hours per month of job coaching
VR Closure: The consumer will be (a) monitored for a minimum of 60 days after the
transition date above to determine whether s/he needs any additional VR services and
(b) closed by DOR thereafter as appropriate.
DOR Counselor Signature:
Email Address:
Phone Number:
Date Signed:
ahamilto
213-736-3904
12/10/2008
@dor.ca.gov
Distribution:
DOR Record of Services
DOR District Office
Regional Ctr. (or other funding source)
Extended Service Provider
SE Service Provider (if different from ESP)
NOTICE: This is confidential information from the records of the California Department of Rehabilitation. State and federal law and
departmental regulations prohibit you from making any further disclosure of this information without the informed, written consent of the
person to whom this information pertains.
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