Phone Once you complete this form, one of our Ticket to Work Intake Specialists will call you to discuss your goals and that the next steps are. First Name * Age * City * Last Name * Email Address * State * – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Contact Number * What is the best time to reach you? Please check all that apply. * Morning Afternoon Evening Type of Phone * Mobile Home Work What is your preferred method of contact? * Phone Email Both Are you a Veteran? * Yes No Do you currently receive Social Security Disability Insurance (SSDI) or Social Security Income (SSI) benefits? Check the benefits you currently receive. * SSDI SSI Both SSDI and SSI None Are you interested in becoming financially independent? * Yes No Please select your immediate plan regarding work: * Work full-time Work part-time and transition to full-time Work part-time only Work and go to school Education and Training only I do not think that any option matches my career goals What type of work are you looking for? * If you are working, how much do you earn each month (gross amount)? * Are you currently employed? * Yes No Have you previously received services from a Vocational Rehabilitation (VR) agency? * Yes No When did you last work? * Have you ever participated in the Ticket to Work program? * Yes No What type of support are you interested in receiving? Please check all that apply. If you do not see an option you are looking for please select other. * Resume development Assistance with applying for jobs Interview preparation Benefits Counseling for SSA benefits Help requesting an accommodation at work Assistance with transitioning to a job Job retention services Job coaching (help at work from a job coach) Other Is there anything else you would like us to know about you? * Date * Thank you for taking the time to complete this survey. A representative from Community Integrated Services will contact you shortly about the Ticket to Work program and your work goals!
