Work With Us

Forms

Please note, if you are seeking career counseling or mental health services, please use the Contact Form located on our Contact Us page.

WCC VR-06

Please complete this required form if you are referring a Maryland WCC case.

MalcolmDubato Provider #165

Contact us for staff practitioner numbers, or refer to the WCC’s Listing of Registered Vocational Rehabilitation Counselors.

Get PDF Form

Referral Form - Workers' Compensation Cases

"*" indicates required fields

Services Requested (check all that apply)*

Employer/Insurer Information

Name
Address

Claimant Information

Name
Address
MM slash DD slash YYYY
MM slash DD slash YYYY

Claimant Attorney Information

Name
Address

Defense Attorney Information

Name
Address

Referral Form - Personal Injury/General Liability Cases

"*" indicates required fields

Services Requested (check all that apply):*

Case Information

Plaintiff Name
Defendant Name
MM slash DD slash YYYY
MM slash DD slash YYYY

Referral Source Information

Referral Source
Name
Address

Billing Information

Billing Name
Billing Address

Forms & Resources For Vocational Clients

Sample Employment Application

Please complete this sample employment application and submit it to your vocational consultant for review.

Sample Application

Independent Job Search Form

Please submit your IJS form to your vocational consultant before the close of business [5:00 p.m.] on your assigned due date. You may complete the form below or the paper copies provided to you.

IJS Form

Post-Interview Assessment

Please complete and submit this form to your vocational consultant after each interview.

Post-Interview Assessment

Resources

Job Search Websites:

Computer Skill Enhancement Websites:

Can't Find An Answer?
Ask Us.

"*" indicates required fields

Looking for Vocational Rehabilitation?

Call MalcolmDubato, LLC today at

410-442-0280

Please complete our Referral Form for Workers’ Compensation Cases