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Secure Self-Referral Form
Are you enrolled with Vocational Rehabilitation

Thanks for submitting! We'll be in touch soon.

This Self-Referral form is for our DKA Choices program. To apply for the Men's Community Closet, please fill out the application under the 'Programs' tab

DKA is an Arizona Health Care Cost Containment System (AHCCCS) Specialty Provider. 

*Potential clients MUST either be referred by DES Vocational Rehabilitation, or be receiving AHCCCS health benefits with either Arizona Complete Health (AZCH), Banner Health, American Indian, or United Health Care. Once they submit a self-referral form, we will reach out to schedule a clinical assessment with our staff to determine eligibility. These requirements do not apply to our Dress for Success Men's clothing closet. 

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DKA, Inc. complies with all applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. DKA provides culturally and linguistically appropriate services and reasonable accommodations for people with disabilities. If you believe your rights have been violated you may file a grievance in person or by mail, fax, or email to DKA, Inc., 1502 E. Broadway, Tucson AZ 85719 or Phone: 520 790-7677; Fax: 790-7786; or Email: Sharris@Dkajobs.com

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You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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