Vocational Rehabilitation Program Application - Jewish Family and Children’s Service of Minnesota

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Vocational Rehabilitation Program Application

Please answer the questions below so we can determine which of our Vocational Rehabilitation programs is the best ﬁt. The information you provide will help us assess your eligibility. If you are eligible, we will follow up regarding next steps. *All ﬁelds are required. If a ﬁeld does not apply to you, enter N/A.

Full Legal Name(Required)

First Last

Preferred Name (if any)

First

Address(Required)

Street Address County City State ZIP Code

Email(Required)

Phone(Required)

Diagnostic Information:

Physical, cognitive, or mental health condition(s) that impact your ability to work:(Required)

If you do not have a physical, cognitive, or mental health condition, write “N/A”

Can you provide documentation of the condition upon intake into the program?(Required)

Yes

No

Are you receiving waivered service(s)?(Required)

Yes

No

If yes, what waiver(s):

Employment Information:

Current Employer(s):(Required)

If you are not currently employed, write “Not Employed”

Number of hours worked per week:(Required)

Functional Limitations:

How does your condition impact your work?

Communication(Required)

Limited ability to give and receive information through words or concepts via reading, writing, speaking, listening, or other adaptive methods.

Yes

No

Mobility(Required)

Limitations in physical and/or psychological ability to move from place to place.

Yes

No

Interpersonal Skills(Required)

Limited ability to establish and maintain relationships.

Yes

No

Self-Care(Required)

Limited ability to perform the skills needed to manage one’s self or living environment.

Yes

No

Self-Direction(Required)

Limited ability to independently plan, initiate, organize, or carry out tasks or problem-solve.

Yes

No

Work Skills(Required)

Limitations in the ability to do specific tasks required to carry out job functions.

Yes

No

Work Tolerance(Required)

Limitation in capacity and/or endurance to perform jobs requiring various levels of physical and/or psychological demands.

Yes

No

Demographic Information:

Are you eligible to work in the United States?(Required)

Yes

No

Do you identify as a person of color?(Required)

Yes

No

Do you have stable housing?(Required)

Yes

No

Do you have a criminal record?(Required)

Yes

No

Do you have a high school diploma or GED?(Required)

Yes

No

Are you a veteran?(Required)

Yes

No

What is your gender?(Required)

Acknowledgment & Signature(Required)

By signing below, I conﬁrm that the information provided is accurate to the best of my knowledge.

I understand that JFCS will follow up for veriﬁcation. If I do not meet eligibility criteria or are unable to provide documentation, I may not be enrolled in a program.

Name (as signature)(Required)

Date(Required)

MM slash DD slash YYYY

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Jewish Family and Children’s Service of Minnesota

5905 Golden Valley Rd, Golden Valley, MN 55422

952-546-0616 | 952-593-1778 fax

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