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How to apply Applying for VR services requires a series of steps:1. An individual provides information to VR staff during an intake interview.Information requested by IDVR is necessary to begin the eligibilityassessment process.And2. An individual agrees that he or she is available to complete theassessment process required to determine eligibility for VR services.And3. At the intake interview, the individual provides a signed and datedapplication signature sheet to IDVR or makes an alternative request forapplication to IDVR.The application process is complete when all steps have occurred.It is helpful to complete the attached intake form and provide it to VR at your firstappointment. However, you are not required to complete an intake form toschedule an appointment or meet with a VR counselor.Contact your local VR office if you have additional questions about eligibilityrequirements, the application process, or would like to apply for services.We look forward to working with you!Idaho Division of Vocational RehabilitationRevision Date: 06/13/191
Intake(All information is important-please complete all fields)I am a previous VR Customer:YesNoIf yes, where?My Personal Information:SS#:Last Name:First Name:Middle Name:Preferred Name:Birth Date:Gender://MaleDo not wish to gender identifyFemalePrevious Last Name:Address:Home Address:City:Zip Code:State:County:Check if mailing address is the same as home addressMailing Address:City:StateCounty:Zip Code:Primary Phone:(Secondary Phone ()) -VoiceVoiceVideoVideoText (SMS)Text (SMS)Email:Revision Date: 06/13/192
Ethnicity (must check one):Hispanic/LatinoNot Hispanic/LatinoRace: (must check one or more:American Indian or Alaska Native (tribal affiliation):AsianBlack/African-AmericanNative Hawaiian or other Pacific IslanderWhiteYesAre you legally able to work in the United States?Are you your own legal guardian?Legal guardian’s name:Guardian’s phone:YesNoNoVPVoiceFaxContacts: (Examples: Family, Friends, PO, Case Worker Etc.)PhoneRelationshipNameExt.# Voice/VP/Fax1.() -2.() -3.() -What are your current living arrangements?Private Residence (home, apt, live w/ family)Adult Correction FacilityCommunity Residential/group homeHalfway HouseHomeless/ShelterMarital Status:MarriedSeparatedMental Health FacilityNursing HomeOtherRehabilitation FacilitySubstance Abuse Treatment CenterNever MarriedWidowedDivorcedWho referred you to VR?Revision Date: 06/13/193
Financial:Including yourself, number in household:Number of Dependents:Primary source of income/financial support:Personal Income (Employment earnings, interest, dividends, rent, retirement, and/or Social Security Retirement Benefits)Family & FriendsPublic Support (SSI, SSDI, TANF, etc.)All Other Sources (e.g. private disability insurance, private charities, child support etc.)SSDI Status:SSI Status:AllowedAllowedSSI Aged: SSI Disabled: SSDI: DeniedDeniedPendingPendingVA: TANF: TANF end date:Not an applicantNot an applicantWorkers' Comp: Unemployment Ins. Other Public Support: I have one or more of the following medical insurances:MedicaidMedicareNonePrivate insurance (Employer Pending)Private insurance through other meansPrivate insurance through own employerPublic insurance from other sourcesState or Federal Affordable Care ActEmployment:I am requesting VR Services to Maintain Current EmploymentYesNoMy Work History:(Starting with most recent and include applicable volunteer work)#1 Employer:Job Title:Job Duties:Hourly Wage:Weekly hours worked:Start Date:End Date:Reason for leaving:How did you get this job:What duties did your disability make more difficult to perform:Was a special license required (CNA, CDL, etc.):Can you return to this job?YesNoIf not, why:Could someone at this employment give you a reference?Who?Revision Date: 06/13/19YesNo4
#2 Employer:Job Title:Job Duties:Hourly Wage:Weekly hours worked:Start Date:End Date:Reason for leaving:How did you get this job:What duties did your disability make more difficult to perform:Was a special license required (CNA, CDL, etc.):Can you return to this job?YesNoIf not, why:Could someone at this employment give you a reference?Who?YesNoYesNo#3 Employer:Job Title:Job Duties:Hourly Wage:Weekly hours worked:Start Date:End Date:Reason for leaving:How did you get this job:What duties did your disability make more difficult to perform:Was a special license required (CNA, CDL, etc.):Can you return to this job?YesNoIf not, why:Could someone at this employment give you a reference?Who?Revision Date: 06/13/195
#4 Employer:Job Title:Job Duties:Hourly Wage:Weekly hours worked:Start Date:End Date:Reason for leaving:How did you get this job:What duties did your disability make more difficult to perform:Was a special license required (CNA, CDL, etc.):Can you return to this job?YesNoIf not, why:Could someone at this employment give you a reference?Who?YesNoYesNo#5 Employer:Job Title:Job Duties:Hourly Wage:Weekly hours worked:Start Date:End Date:Reason for leaving:How did you get this job:What duties did your disability make more difficult to perform:Was a special license required (CNA, CDL, etc.):Can you return to this job?YesNoIf not, why:Could someone at this employment give you a reference?Who?Revision Date: 06/13/196
Veteran:YesNoDisabilities:Please describe your disabilities and functional limitations:(Physical, Injuries,Mental Health, Depression, Substance Abuse [drug and/or alcohol], LearningDisability, etc.)My disability makes it difficult to? (Describe how it affects you in the space provided)StandWalkSitLiftBendUse hands or emberLearnUnderstandExplain:Handle StressControl EmotionsWork with othersCommunicateExplain:OtherExplain:How do your disabilities affect your current ability to work or keep a job?How do you think Vocational Rehabilitation can help you get a job and keep one?What are your employment needs?Revision Date: 06/13/197
Are you receiving services or funding from any of these programs?Adult Education and Literacy Program (AE)Adult Program (Department of Labor)Dislocated Worker (Department of Labor)Employment Services (Department of Labor)Job CorpsYouth (Department of Labor)YouthBuildNoneFoster Care:Date Started:Date Started:Date Started:Date Started:Date Started:Date Started:Date Started:Yes; is currently in foster care or was previously in foster care.No; has never been in foster care.YesNoDoes not wish to self-identifySingle Parent:(Currently a single parent with a dependent child under 18 or is pregnant)Displaced HomemakerYesNo(was providing services to family member(s) while dependant upon another familymember's income or due to military service of a spouse)Migrant or Seasonal FarmworkerYesNoLow income, primarily employed for last 12 to 24 months in farming laborIs a seasonal farmworker and distance to job site does not allow for daily return topermanent homeIs a Dependent of migrant/seasonal farmworkerDo you have a driver's license?YesDo you drive / mode of transportation?Do you require communication assistance?Explain:Other needs request:Revision Date: 06/13/19NoYesNo8
Highest level of education at referral:No Formal EducationAssociate's degreeElementary Education- 1 2 3 4 5 6 7 8Bachelor's degreeSecondary Education, no high school9 10 11 12diploma-Master's degreeAny degree above a Master’s (PhD,EdD, JD)12th Grade (18-21 services)Career / Technical Training ProgramHigh school diploma(No Credential)GEDCareer / Technical Training ProgramAdult Secondary Education (AE-GED)Postsecondary- 1 2 3 4(Credential)Completion Date (month/year) for HighestLevel of Education checked above:If I am attending school, the name of the school is:If I am attending school, I am currently in what year/grade:(H.S. 9th , 10th , 11th , 12th , 18-21; GED, ABE, Career/Tech-Credited/Non,Postsecondary 1st, 2nd, 3rd, 4th year; Higher than Bachelor’s)I am a student with a disability in high school:I have a current 504 Accommodation Plan:I have a current IEP:YesYesYesNoNoNoWhat month/year did you start high school:What month/year did/will you graduate:Graduation date for highest level of education:Have you been convicted of a felony or a misdemeanor?Offense(s):Date of Conviction(s):State Where Conviction(s) occurred:Probation/Parole officer is:IDOC #Date Probation Started:Completion Date:Restitution owed:Revision Date: 06/13/19YesNo9
*******Agency Use Only*******Next step in establishing eligibility:Counselor additional information or comments:Revision Date: 06/13/1910
Idaho Division of Vocation
