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Vocational Rehabilitation Services
If a doctor decides that due to your injury you will not be able to return to your job you may be eligible for vocational rehabilitation services. The goal of vocational rehabilitation is to get you back to work earning as close as possible to what you were making prior to your injury. Vocational rehabilitation services cover all non-medical services that you may require to return to a suitable job.

Services may include: evaluation of your capabilities; vocational testing; counseling or guidance; workplace modifications; and/or, job placement assistance/formal retraining.

If you request to meet with a vocational rehabilitation review officer you must attend the meeting. The meeting determines if you are a suitable candidate for rehabilitation services. If you do not attend this meeting your benefits can be discontinued. If you refuse to take part in a rehabilitation program after being determined suitable, your weekly benefits can be reduced by the insurance company, with the permission of the DIA.

Filing a workers' compensation claim is a complicated and difficult task. If you would like your claim to be reviewed by an attorney, complete the form below for a free evaluation.

Free Vocational Rehabilitation Services Consultation

Title:
First Name:	*
Middle Name:
Last Name:	*
Home Phone:	*
Cell Phone:
Work Phone:
Email Address:
Address:	*
City:	*
State, Zip:	* *
What is the best way to reach you? Please provide the best place, time and method for contacting you.

Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Accident:	*
City where accident occured:	*
State where accident occured:	*

Please briefly explain the incident that caused the injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

Yes No

Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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