Customized Employment Intake Form

This example, Customized Employment (CE) Intake form, illustrates how person-centered planning is translated into actionable steps. It demonstrates how discovery, team collaboration, and individualized goals guide service planning, timelines, and communication strategies to support meaningful employment outcomes.

This document should be completed during intake prior to Discovery along with your agency’s typical forms. You will complete a CE Intake form with your learning partner and submit it during week three.

KY_CEIntake_pilot2026Download

CE Intake

Employment Seeker: Jordan M 

Employment Specialist: Taylor M 

Understanding Customized Employment 

X  Reviewed Introduction to Customized Employment (handout) 

Team Members  

Name  Role/Relationship  Contact Information   Chooses (or supports) CE services 
Jordan Miller  Employment seeker  555-123-4567  yes 
Morgan Miller  Parent/legal guardian  555-123-4567  yes 
Alexis Parker  VR Counselor  555-234-5678  yes 
Riley Brooks  Care Coordinator  555-345-6789  yes 
Charlie Bennett  Living Support  555-456-7890  yes 
Taylor Morgan  Customized Employment Specialist  555-567-8901  yes 

Financial and Non-Financial Employment Goals 

  1. Financial Goals: Jordan would like to earn money to do more shopping for themselves, buying makeup and their favorite foods. 
  1. Non-Financial Goal: Jordan would like to become more independent in the community and be helpful to their parent, who is older and is physically unable to keep up with home maintenance 

Employment and Supplemental Services/Programs Currently Used or to be Explored 

Service/Program  Currently Using, Referral Needed, Not Interested  Plan 
Employment services or supports (e.g., PASS, VR, Medicaid HCBS, etc.)  Exploring options  Jordan and the team are considering employment services through ACCES-VR and will verify if Medicaid is available for ongoing job coaching support. 
Benefits Planning  Will need  Benefits advisement will begin through a referral from VR, with a transition to the benefits specialist on the team as needed. 
Universal and Assistive Technology Expert  Will need  Uses smart smartphone, needs to explore 
Transportation Options  Uses public transportation; with support, knows specific routes   
Other     
Other     

CE Estimated Timeline 

  1. Discovery: 
Discovery Stages  Estimated Dates 
Stage 1: Home visit, community exploration, conversations with important people, familiar Discovery activities (weeks 1-4)  12/11/2025 – 1/16/2026 (adjusted for holidays) 
Stage 2: Unfamiliar Discovery activities, informational interviews, and verifying vocational themes (weeks 5-10)  1/17/2026 – 3/30/2026 
Stage 3: Career narrative (weeks 11-12)  3/31/2026 – 4/10/2026 
  1. Customized Job Development 
Customized Job Development Stages  Estimated Dates 
Stage 1: Create employment plan (weeks 11 – 12)  4/10/2026 – 4/17/2026 
Stage 2: Informational interviews, proposals, and negotiation (weeks 13 – 24)  4/17/2026 – 6/30/2026 

Home Visit Planning 

  • When (date/time): 12/12/2025 @ 3 PM 
  • Who will participate: Taylor Morgan (CES), Morgan Miller (Parent), Jordan Miller (employment seeker) 
  • Strategies for successful home visit: Prior to the home visit, discuss what the home environment entails. This can help reduce anxiety for Jordan and allow time to prepare the space comfortably. 

Community/Neighborhood Observation Planning 

  • When (date/time): 1/8/2026 (weather permitting) 
  • Who will participate: Jordan Miller and Taylor Morgan 

Communication Plan 

The following plan outlines when and how the employment specialist will communicate with Jordan and team members: 

Team Member  When (as needed and at least weekly, monthly, quarterly)  How (phone, email, in-person, etc.) 
Employment seeker  Weekly  In person; Phone 
Family  Bi-weekly  In person; Phone 
Funder (e.g., VR counselor, case manager)  Monthly  In person, Phone 
Other:     
Other