Job Seeking Skills (JSS) Referral Form

You may submit a referral using the online form below, or download a printable PDF version of the form to complete and send via fax to 919-846-4740, or mail to: Carolina Case Management
118 Wind Chime Court
Raleigh, NC 27615
Download PDF Form Here.

CLIENT INFORMATION
Injured Worker's Name (First, Middle Initial, Last)	Today's Date
Address	Telephone
City, State, Zip Code	# Months/Years out of work
CLAIMS ADJUSTER
Claims Adjuster Name (first, middle, last)	Attorney Name
Claims Adjuster Address (street, city, state, zip)
CURRENT WORK RESTRICTIONS (if applicable)
CLIENT DETAILS
Previous Job Title	Employer
Claims Adjuster Address (street, city, state, zip)	Hobbies
Types of Employment Interests
Transferrable Skills (what other jobs can client perform? list below)
CASE MANAGER
Medical Case Manager Name	MCM email
Vocational Case Manager Name	VCM email
Thank you for your referral.