9.5 Documentation of Comprehensive Assessment

The DVR Counselor shall document the comprehensive assessment using the agency approved form and supported by case notes and other case documentation when appropriate. This required form shall be contained in the individual’s service record within DVR’s electronic case management system and shall document the DVR Counselor’s written analysis of the rehabilitation needs identified to address the individual’s vocational barriers as necessary to attain an appropriate employment outcome. The DVR Counselor’s written analysis shall identify the employment outcome chosen by the individual and address the suitability of the goal given the individual’s unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice. It is appropriate to discuss alternatives that were explored but not selected by the individual. Documentation shall also reflect the provision of vocational guidance and counseling between the DVR Counselor, the individual, and, as appropriate, their authorized representative, to ensure that the individual was an informed decision maker throughout the comprehensive assessment analysis.

If, in the DVR Counselor’s professional opinion, the requested employment outcome is not appropriate given the assessment data, and/or a requested rehabilitation service(s) is not necessary or not appropriate, the DVR Counselor shall not approve an IPE containing these items. Documentation in the service record shall clearly reflect the DVR Counselor’s rationale for this determination.

The agency-approved comprehensive assessment form shall be completed in the electronic case record each time the DVR Counselor and the individual agree upon a change in employment outcome.