Service Questionnaire (Vocational Rehabilitation Services)



|[pic] |Service Questionnaire |

If you need help filling out this form please call the Vocational Rehabilitation office before your first appointment. We can help!

You can get this document in other languages, large print, braille or a format you prefer. Contact Vocational Rehabilitation at 503-945-5880 or email @state.or.us. We accept all relay calls.

|Personal information |

|Last name: |First name: |

|      |      |

|Middle name: |Preferred name and pronouns: |

|      |      |

|Previous name(s): |Birthdate: |

|      |      |

|Email address: |

|      |

|Gender: |Social Security number: |

|      |    -    -      |

|Phone number: |Second phone number: |

|      |      |

|Cell Landline |Cell Landline |

|VP (video phone) Fax |VP (video phone) Fax |

|Home address: |Lived there since: |

|      |      |

|City: |State: |County: |ZIP code: |

|      |      |      |      |

|Mailing address (if different than above home address): |

|      |

|City: |State: |ZIP code: |

|      |      |      |

|Racial and ethnic background (check all that apply): |

|How do you identify your race, ethnicity, tribal affiliation, country of origin or ancestry? |

|      |

|Which of the following describe your racial or ethnic identity? (Check all that apply) |

|American Indian or |Middle Eastern/Northern African |

|Alaska Native |Middle Eastern |

|Alaska Native |Northern African |

|American Indian |Native Hawaiian or Pacific Islander |

|Canadian Inuit, Metis, or |Guamanian or Chamorro |

|First Nation |Native Hawaiian |

|Indigenous Mexican, Central American, or South American |Samoan |

|Asian |Other Pacific Islander |

|Asian Indian |White |

|Chinese |Eastern European |

|Filipino/a |Other White |

|Hmong |Slavic |

|Japanese |Western European |

|Korean | |

|Laotian | |

|South Asian | |

|Vietnamese | |

|Other Asian | |

| | |

|Black or African American | |

|African (Black) | |

|African American | |

|Caribbean (Black) | |

|Other Black | |

|Hispanic or Latino/a | |

|Hispanic or Latino/a Central American | |

|Hispanic or Latino/a South American | |

|Hispanic or Latino/a Mexican | |

| |Other Categories |

| | Other (please list): | |

| |      | |

| | Don’t know/Unknown |

| |Are you an enrolled member of a federally recognized Tribe? |

| | Tribal ID: | |

| |      | |

| | CIB: | |

| |      | |

| |Tribal affiliation: | |

| |      | |

| | Don't want to answer/Decline |

|Preferred language: What language do you want us to use |

|with you? |

|Speaking: | English | Spanish | ASL |

| | Other: |      | |

|Writing: | English | Spanish | Other: |      |

|Do you need an interpreter for us to communicate with you? |

| No | Don’t know/Unknown | Don’t want to answer/Decline |

| Yes, sign language. What kind? (ASL, PSE, ProTactile, etc.) |

| |      | |

| Yes, spoken language. Which language? |      |

|If there is a bilingual VR Counselor* available, do you want to be assigned to their caseload? |

| Yes No |*Bilingual staff have passed a formal language proficiency test |

|How well do you speak English? |

| Very well | Well | Not well |

| Not at all | Don’t know/Unknown | Don’t want to answer/Decline |

|Have you been a VR client before? Yes No |

|If yes, where (city/state) and when (year)?       |

|Are you a U.S. citizen? | Yes |If no, do you have documents that show you can legally work in the United States?| Yes |

| |No | |No |

|Emergency contact(s) (Optional): |

|Name: |Relationship: |Phone or email: |

|      |      |      |

|Name: |Relationship: |Phone or email: |

|      |      |      |

|Your living arrangement |

| Private home or apartment (you pay rent or mortgage with or without housemates) |

| Live with parents (in their home) | Community residential or group home |

| Inpatient drug/alcohol treatment | Halfway house |

| Dorm or school-based housing | Homeless or in a shelter |

| Other |

|Marital status: | Never | Married | Divorced |

| |Separated |Widowed |Domestic partnership |

|Household members (do not include roommates you split |

|costs with) |

| I live alone | Self and partner or spouse | Parents |

| Children under 18 |How many? |How old are they? |

| |      |      |

|Who referred you to VR? (Name of person or organization) |

|      |

|What is their email or phone number? |

|      |

|Your income |

|How do you currently support yourself? |Amount: |

|Supplemental Security Income (age 16–64) (SSI): |$       | |

|Social Security Disability Income (SSDI): |$       | |

|Supplemental Security Income (age 65+) (SSI): |$       | |

|Temporary Assistance for Needy Families (TANF): |$       | |

|Supplemental Nutrition Assistance Program (SNAP): |$       | |

|Unemployment Insurance (UI): |$       | |

|Workers’ Compensation Time Loss: |$       | |

|Veterans’ benefits: |$       | |

|Income from spouse, partner or family members’ job(s): |$       | |

|Income from my job: |$       | |

| Other (specify):       |$       | |

|Total: |$ 0[pic]0.00 | |

|Do you have a court appointed legal guardian? No Yes |

|If yes, what is their name and phone number and/or email? (Please bring court papers to your first meeting with VR) |

|      |

|Do you have a representative payee? No Yes |

|If yes, what is their name and phone number or email? |

|      |

|Medical insurance information |

|Check all that apply: | None |

| OHP (Oregon Health Plan) | Private insurance through my job |

| OHP Plus | Not yet eligible for insurance |

| |from my job |

| ACA Exchange | Private insurance (other sources) |

| Medicare | Public insurance (other sources) |

| Medicaid | Workers’ Compensation |

|Insurance company and ID number(s):       |

|Medicare/Medicaid number:       |

|OHP Plan and ID number:       |

|Education information |

|High school |

|School(s) you attended |City and state |When (years) |

|      |      |      |

|      |      |      |

|Did you graduate from high school? |

| No |What is the highest grade you completed?       |

| Yes | Standard Diploma |

|When? (month and year) |Modified Diploma |

|      |Certificate of Completion/Attendance |

| |GED |

|Were you in special education classes? | Yes No |

|Did you have an IEP (Individualized Education Program)? | Yes No |

|Did you have a 504 Plan? | Yes No |

|Were or are you a participant in a Youth Transition Program (YTP)? | Yes No |

|District and school name:       |

|City and state:       |

|College; university; or military, technical or trade |

|training school |

|School name |Start date |End date |Degree or certification |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|Are you currently attending college or | Yes No |

|an apprenticeship? | |

| |If yes, where (name of school)? |      | |

| |Are you currently in default on | Yes No |

| |any federal student loans? | |

|Employment information |

|Are you working now? |Last month and year that you worked: |

|Yes No |      |

|Salary or hourly wage: $       |Hours per week:       |

|Work history (please list your most recent job first) |

|Employer 1: |Job title: |

|      |      |

|Location (city and state): | Full time Part time |

|      | |

|Job duties:       |

|Did your disability cause you problems at work? Yes No |

| |If yes, how?       |

|Start date: |End date: |Last salary/pay rate: |

|      |      |      |

|Reason for leaving: |

|Fired Laid off Quit Moved or relocated |

| Other (please explain): |      | |

| |

| |

|Employer 2: |Job title: |

|      |      |

|Location (city and state): | Full time Part time |

|      | |

|Job duties:       |

|Did your disability cause you problems at work? Yes No |

| |If yes, how?       |

|Start date: |End date: |Last salary/pay rate: |

|      |      |      |

|Reason for leaving: |

|Fired Laid off Quit Moved or relocated |

| Other (please explain): |      | |

| |

| |

| |

| |

|Employer 3: |Job title: |

|      |      |

|Location (city and state): | Full time Part time |

|      | |

|Job duties:       |

|Did your disability cause you problems at work? Yes No |

| |If yes, how?       |

|Start date: |End date: |Last salary/pay rate: |

|      |      |      |

|Reason for leaving: |

|Fired Laid off Quit Moved or relocated |

| Other (please explain): |      | |

| |

|Unpaid, volunteer or internship experiences |

|Volunteer or internship position 1: |Organization or site: |

|      |      |

|Location (city, state): | Full time Part time |

|      | |

|Duties:       |

|Did your disability cause you problems here? Yes No |

| |If yes, how?       |

|Start date:       |End date: |Last salary/pay rate: |

| |      |      |

|Reason for leaving: |

|Fired Laid off Quit Moved or relocated |

| Other (please explain): |      | |

| |

| |

|Volunteer or internship position 2: |Organization or site: |

|      |      |

|Location (city, state): | Full time Part time |

|      | |

|Duties:       |

|Did your disability cause you problems here? Yes No |

| |If yes, how?       |

|Start date: |End date: |Last salary/pay rate: |

|      |      |      |

|Reason for leaving: |

|Fired Laid off Quit Moved or relocated |

| Other (please explain): |      | |

| |

| |

|Do you need VR to help keep your job? | Yes No |

|Are you a migrant or seasonal farmworker? | Yes No |

|Are you a veteran? | Yes No |

|Were you injured during your military service? | Yes No |

|Are you working with a mental health program? | Yes No |

|Are you part of the Lane v. Brown class action? | Yes No |

|Disability information |

|Please list your health conditions, disabilities or diagnoses (physical, mental or emotional). List them in order putting the most severe/hardest to deal with |

|FIRST. |

|Condition or diagnosis |Year of onset/when started: |How it affects me: |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|Please list any medications or supplements that you are currently taking for any of the conditions listed above (you can add a page with your list on it if that is |

|easier): |

|Medication or supplement |Purpose |

|      |      |

|      |      |

|      |      |

|Information about your doctors and providers |

|Name |Address |Phone |Reason you see this person |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|Special programs (check all that you are involved with) |

| None | Tribal Vocational Rehabilitation |

| Aging and People with Disabilities (APD) | Intellectual and Developmental Disability Services: Support services brokerage |

| Independent Living | State Developmental Disabilities Services: Other programs |

|Center (IL) | |

| Developmental Disability Services: County case management | Oregon State Hospital (OSH) |

| Oregon Commission for the Blind (OCB) | Preferred Worker Program/Workers Compensation |

| Oregon Youth Authority (OYA) | Supplemental Nutrition Assistance Program (SNAP) |

| Stabilization and Crisis Unit (SACU) | Temporary Assistance for Needy Families (TANF) |

| Supported mental health (OSECE) | WorkSource |

|Other places you get support or help |

|Please list any contacts at the other agencies and organizations you are currently involved with. |

|Name of agency |Contact person |Phone number and email |

|      |      |      |

|      |      |      |

|      |      |      |

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|      |      |      |

|      |      |      |

|Your goals |

|What services do you think you might need from Vocational Rehabilitation to be successful at getting a job or keeping your current one? (Check all that apply) |

| Help picking a job goal | Learn how to look for work and interview |

| Help with medical equipment | Learn how to work with my disability |

|Other (please explain):       |

|What are your strengths and skills? |

|      |

|What type(s) of work are you interested in doing? |

|      |

|How many hours a week do you want or need to work? |

| Full time | Part time hours per week: |      | Not sure |

|How do you get around? Bus Car Bike Other |

|Do you have a valid driver’s license? | Yes No |State:       |

|Do you have valid insurance? | Yes No |

|Do you have a clean driving record? | Yes No |

|If no, please explain:       |

|Have you ever been arrested or convicted of a crime (felony or misdemeanor)? | Yes No |

|If yes, please explain:       |

|Is there anything else we should know about you and |

|your goals? |

|      |

|Thank you for taking the time to answer these questions. This information will help us make your services better. |

|Please bring this to the appointment with your VR Counselor! |

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