Vocational Services Referral Form

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Home
About
Service
Contact

Carly Coughlin,MS,CRC
Vocational Counselor
Ph: (775)682-1599
F:(775)201-0278

Physical Address:
433 W.Plumb Lane
Reno, NV89509

Mailing Address:
316 California Ave.#407
Reno, NV89509

New Referral Form

* Indicates required field

Date of Referral *

Please attachthe following: PPD, FCE, Job Description (if available) *

Max file size: 20MB

Injured Worker Name *

First

Last

Injured Worker Claim Number *

Adjuster Name and Company *

Adjuster Mailing Address *

Daily Rate *

Physician *

D.O.B *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Social Security Number *

Date of Injury *

Injured Body Parts *

Job Title/Employer *

Return to work options with Employer of Injury? *

Yes No Unknown

Is employee currently working? *

Yes No

Is employee medically stable? *

Yes No

PPD *

Yes No

FCE *

Yes No

Attorney Name *

Other Notes/Misc *

Submit

PAYMENTS SHOULD BE MAILED TO: 433 W. Plumb Lane Reno, NV 89509
EIN: 85-4366819

Thank you for this referral

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Vocational Expert, Vocational Counselor, Vocational Rehabilitation Counselor

Address: Coughlin Vocational Counseling
433 W. Plumb Lane
Reno, NV
89509

Telephone: 775-682-1599

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Carly Coughlin,MS,CRCVocational CounselorPh: (775)682-1599F:(775)201-0278

New Referral Form

PAYMENTS SHOULD BE MAILED TO: 433 W. Plumb Lane Reno, NV 89509EIN: 85-4366819​

Location

What Our Clients Are Saying

Contact Us

Subscribe Today!

Carly Coughlin,MS,CRC
Vocational Counselor
Ph: (775)682-1599
F:(775)201-0278

PAYMENTS SHOULD BE MAILED TO: 433 W. Plumb Lane Reno, NV 89509
EIN: 85-4366819