RISE Registration and Referral Form
If you require a special accommodation or have other special needs, please request that information in the form below 10 working days before the first class meeting.
Email address
DORS Counselor Info
Counselor's Full Name
Your answer
DORS Office Address
Your answer
DORS Counselor Phone
Your answer
DORS Office Fax
Your answer
Counselor Email Address
Your answer
Applicant Info
Applicant's Full Name
Your answer
Address
Your answer
Phone
Your answer
Email Address
Your answer
Date of Birth
MM/DD/YYYY
Your answer
Gender
DORS Participant ID
Your answer
RISE Services
Select the appropriate RISE course or program for this submission
Please check all relevant services
You may select multiple courses and services. Use the text box labeled "Other" to provide us with specific requestes
Required
Course Date
MM/DD/YYYY (if NOT interested in class, enter date of referral)
Your answer
Additional Course Date
MM/DD/YYYY (if applicable)
Your answer
Course Location
(If applicable)
Your answer
Additional Course Location
(If applicable)
Your answer
RISE Option Requested
RISE Option
Note: Supported Business Enterprise is only for consumers who are eligible for long term supports from MHA or DDA
Supported Employment Provider Agency:
(If applicable)
Your answer
Proposed Business
If known
Your answer
Disability Information
Disability Information
Select all that apply. Add as much detail as possible under "other".
Required
Benefits Information
Benefits Information
Select one:
Ethnic Information
Ethnic Information
Select one:
Veterans Information
Are You a Veteran?
Select one:
Special Accommodation Request:
Special accommodations will be provided upon request (with 10 business days notice). Please specify below:
Is an interpreter required?
If an interpreter is required, what type is needed?
Special Accommodation Requirements
Select all that apply:
Please complete the captcha before submitting the form.
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