*First Name:		*Last Name:
Social Security Number(SSN):		*Date of Birth:
Gender:	Male Female Other
*Address Street:
Address Apt:		Address City:
Address State:	District of Columbia Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana Nort Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Virginia Vermont Washington Wisconsin West Virgina Wyoming	Address Zip-Code:
*Best Contact Telephone No:		Video:
TTY:		VRS IP:
E-mail:		DC Student ID (if applicable):

Race/Ethnicity: check which one(s) apply:
			White
			Black or African American
			American Indian or Alaskan Native
			Asian
			Native Hawaiian or Pacific Islander
			Hispanic or Latino

Please describe your physical or mental impairment that constitutes or results in a substantial impediment to employment.

Please bring documentation, such as medical, mental health evaluations or treatment summaries and the names of any treating health care providers to your first appointment.

*Are you currently employed?

Yes   No If yes, list the Name of Employer, Hours Worked and Hourly Pay:

*Can you legally work in the U.S.?

Yes   No

*Are you currently receiving any of the following benefits?

Yes   No

If yes, check which one(s) apply:
			SSI/SSDI
			Unemployment
			Interim Disability Assistance (IDA)
			Food Stamps
			Survivor Benefits
			Child Support
			TANF

*Do you have Medical Insurance Coverage?

Yes   No

If yes, check which one(s) apply:
			Private Insurance
			Medicaid
			Medicare
			Public Insurance from Other Sources

Do you require any special accommodations for your intake appointment?

Yes   No

Require special accommodations ? Enter details

If applicable, please include the name and contact information of the person who referred you to DDS/RSA
Referral Source (e.g. school, medical professional, DDS/DDA):
Name of Referrer :
Referrer�s Address :
Referrer�s Phone No:

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APPLICATION INSTRUCTIONS AND INFORMATION

Applications may be mailed, faxed or hand-carried to DDS/RSA. DDS/RSA�s mailing address, fax and telephone numbers are:

Department on Disability Services, Rehabilitation Services Administration
Attn: Application for VR Services
250 E Street, SW � 5th Floor
Washington, D.C. 20024
(202) 442-8400 � DDS/RSA Main Line
(202) 442-8720 � DDS/RSA Fax

DDS/RSA will contact you within five business days of the date your application is received to schedule an appointment to meet with a vocational rehabilitation counselor. DDS/RSA will make a determination regarding your eligibility for services within 60 days of receiving your signed application barring exceptional and unforeseen circumstances beyond DDS/RSA�s control. Any information provided in connection with this application is confidential. Such information cannot be released except by direct order of a judge when related to judicial proceedings or written consent by the applicant or his or her representative. All programs and services provided by DDS/RSA are provided on a non-discriminatory basis without regard to race, color, national origin, age, disability, sex, gender identity, sexual orientation, religion, political affiliation, marital status, and familial or parental status. With the exception of diagnosis, counseling and guidance, placement and follow-up, other services provided by DDS/RSA will be based upon the person�s financial resources and other available comparable benefits. A Client Assistance Program (CAP) is available to provide assistance in informing and advising all applicants for services of available benefits under the Rehabilitation Act. Upon request, the CAP may assist each individual in his/her relationship with the projects, programs, and facilities providing services under the Rehabilitation Act as amended, including assistance in pursuing legal, administrative, or other appropriate remedies to ensure the protection of rights under this Act. Individuals who wish to obtain this free assistance from CAP should contact:

University Legal Services
220 I Street, N.E., Suite 130
Washington D.C., 20002
(202) 547-4747
(202) 547-2657(tty)
(202) 547-2662(fax).

If there are any questions about the status of an application or any other service provided by DDS/RSA, please call (202) 442-8400, or walk into our office at 250 E Street, SW, between the hours of 8:15 a.m. and 4:45 p.m.

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I understand that completion of this application means that I intend to go to work.

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