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  Maryland State Department of Education, Division of Rehabilitation Services
Referral for Rehabilitation Services in Maryland
You may refer yourself or a family member for DORS services (employment services or, if you are 55 years or older and are blind/vision impaired, older blind independent living services) in one of the following ways:
Complete and submit this online form. (This is a secure website that sends your information directly to DORS, and not via the Internet.)
Print this form by clicking here, complete and mail it, or bring it to the nearest DORS Office.
Call the nearest  DORS Office or the statewide toll-free number (1-888-554-0334) and complete the referral over the phone.
Visit the nearest DORS Office  and request services.

If you are interested in independent living services (other than older blind), please contact the Center for Independent Living in your area.

All information is confidential and will not be released elsewhere.  We look forward to hearing from you.

Date:   2/27/2015
* = Required Field
First Name *
Last Name *
Please include your email address in the Comments box below.

Are you interested in * Employment Services  Employment Services are for individuals who want to go to work or who need services to maintain their current job.
Older Blind - Independent Living Services Independent Living Services are for individuals who do not have employment goals. DORS provides independent living services only to individuals age 55 or older who have a significant vision impairment or are blind.

Primary Disability * Secondary Disability

Mailing Address *


City *
State *
Zip Code *
County of Residence *
Social Security Number * - -

Gender *


Date of Birth (mm/dd/yyyy)  
Referral Source

Are you receiving Social Security disability benefits?

Special Needs

For example: Do you need a sign language interpreter, foreign language interpreter, large print, Braille, etc.?
Comments / Additional Information
Please include, as appropriate: (1) Your email address; (2) services you are requesting; (3) if you are still in school, the name of your high school; (4) the highest grade you've completed/college degree. If you are filling this application on behalf of someone else, please provide your name, contact information and relationship to the person you are referring in this box.
Division of Rehabilitation Services • 2301 Argonne Drive • Baltimore, MD 21218 • 410-554-9442 • 888-554-0334
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