Schedule-Interview – Asian Rehabilitation

Welcome to ARS!

To schedule a Job Placement Interview, please answer all applicable questions and submit. The client or parent/guardian will be contacted after this form is processed.

For questions or follow-up inquiry, contact Job Placement Specialist Minji Kim via email or (714) 318-2181

NOTE: Although their medical diagnoses can range from moderate to severe, any individual accepted as a client must be diagnosed with a developmental disability before the age of 18 years.

Client Name *

Address *

Address 2

City/Town *

State/Province *

Zip/Postal Code *

Telephone

Email *

Checkboxes

Are you receiving SSI or SSDI and Ticket to Work services?
Are you receiving services from any Regional Center?
Are you receiving services from California State Department of Rehabilitation (DOR)?

Please provide more details about disability/medical history

Parent/Guardian Name

Address

Address 2

City/Town

State/Province *

ZIP/Postal Code

Parent/Guardian Telephone

Parent/Guardian Email *