Nevada Department of Employment, Training and Rehabilitation
Application for Vocational Rehabilitation Service
Case #_
LAST NAME
MIDDLE
INI T IAL
FIRST NAME
PREVIOUS NAMES USED
S O C IA L S E C UR IT Y #
X X X - X X - __ __ __ __
C U RR ENT ST R EE T AD DR E SS
CITY
STATE
ZIP CODE
MAILING ADDRESS (I f D if fere nt From Current Address)
CITY
STATE
ZIP CODE
COUNTY
DATE OF BIRTH
EMAIL ADDRESS
T ELE P HO NE #
(
GENDER
Apt #
CELL#
)
M A L E
F E M A L E
(
)
CONTACT PERSON’S NAME AND TELEPHONE NUMBER (SOMEONE WHOSE PHONE NUMBER IS DIFFERENT THAN
Name:
Relationship:
YOURS WHO WOULD BE ABLE TO GIVE YOU A MESSAGE)
Number: _(
)
Number: _(
)
Contact Person NOT Living in your home
U.S. MILITARY VETERAN?
  YES NO
Name:
Relationship:
Address:_
U.S. CITIZEN?
YES NO
If No: Do you have an Alien Registration Card?
YES NO
EMPLOYMENT AUTHORIZATION
DOCUMENT?
YES NO
RACE (CHECK ONE OR MORE)
WHITE
BLACK OR AFRICAN AMERICAN ASIAN
AMERICAN INDIAN / ALASKA NATIVE NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER
ETHNICITY: HISPANIC/LATINO YES NO OTHER (SPECIFY)
Who referred you? Check / Circle one:
Social Security Administration or Disability Determination Services
Law enforcement, Corrections, Court
Job Connect, Workers’ Comp.
University, College, or Vocational school
Self-referral, Friend, Family
Grade school or high school
Veteran’s Administration
Doctor, Hospital, Mental Health
Rehabilitation program in your community
Welfare or public assistance agency
Other
Please check one of the following which best describes your current living arrangement:
Private residence (On your own, with family or roommate) Group home
Rehabilitation facility
Other
Mental health facility
Nursing home
Jail/Adult correctional facility
 Substance abuse treatment center
Halfway house
Homeless/shelter
Would you like to register to vote today Yes
Please select one: Currently registered
No Form#
Not Eligible
Not Interested
MARITAL STATUS SINGLE
MARRIED
SEPARATED DIVORCED
WIDOWED
Household Information:
Number in Family
Number of Dependents
Parents monthly income if under age 18
House hold members:
Name:
Age:
Relationship:
Occupation:
Name:
Age:
Relationship:
Occupation:
Name:
Age:
Relationship:
Occupation:
Name:
Age:
Relationship:
Occupation:
What is your primary (largest) source of support? Monthly Amount $
Check one of the following:
Your personal income (earnings, interest, dividends, rent)
Your spouse’s income, or support from family and friends
Public support such as SSDI, SSI, TANF, etc.
Other sources such as insurance or charities
DATE RECEIVED
RECEIVED BY:
(FOR OFFICE USE ONLY)
Agency Representative :
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IDENTIFICATION
List A
One (1) Item from List A
OR
One (1) Item from List B AND One (1) Item from List C
List B




List C
Provide verification for the following identification:
United States Passport
Certificate of United States Citizenship
Certificate of Naturalization
Unexpired Foreign Passport w/Attached Employment
Authorization
 Alien Registration Card w/Photograph
What is your highest level of education? Check one:
 State issued Driver’s License or State I.D. Card w/Picture
or Information (Name, Sex, Date of Birth, Height, W eight
& Color of Eyes)
 U.S. Military I.D. Card
AND
 Original Social Security Card to be Witnessed at Intake
 Birth Certificate Issued by State, County or Municipal
Authority
 Unexpired INS Employment Authorization
No formal schooling
Some elementary school (grades 1-8)
Some high school (grades 9-12) but no high school diploma Special education certificate of completion/attendance
High school diploma
GED (high school equivalency certificate)
Name of High School_
Some college/voc-tech – No degree
Present Grade
Vocational/Technical Certificate
Associates Degree
Bachelor’s Degree
Master’s Degree or Higher
College/Vo-Tech Schools :
Name of School:
Address of School:_
How can the Bureau be of assistance to you? What employment related services are you seeking:
Are you working? If yes, where:
If no, check one:
H.S. Student
Other
Other Student
Trainee/Intern/Volunteer
Not Employed
If you are employed, how many hours do you usually work per week?
If you are employed, what are your current WEEKLY earnings? $
(gross wages, salaries, tips or commissions before payroll or tax deductions)
Are you currently receiving any of the following? If yes, please list the MONTHLY amount.
SSDI (Social Security Disability Insurance) Amount: $
SSI (Supplemental Security Income)
Amount: $
TANF (Temporary Assistance for Needy Families) Amount: $
Workers’ compensation
Amount: $
Do you have any of the following types of medical
insurance coverage? Check one or more:
Medicaid
Medicare
Workers’ Compensation
Private insurance through employment
Insurance Company
No Medical Insurance Coverage
Other Public Insurance
Private insurance through other means (for
example, insurance through your parents or spouse)
COMMUNICATION ACCOMMODATIONS
Regular print
Braille
Other language (specify) Large print
What is your primary means of transportation?
Personal Vehicle Public Transportation
Other
General Assistance (Public Assistance)
Veterans’ disability benefits
Any other public support
Amount: $
Amount: $
Amount: $
(Please describe)_
To help us coordinate your services, please check any other
services you are receiving. Check one or more if you are receiving
the following:
Temporary Assistance (TANF) $
General Assistance (GA)
$
Food Stamps $_
Children and Family Services
Foster Care
Child Support Enforcement
Child Care
Adult Protective Services
Low Income Energy Assistance Medicaid
Working Healthy
Other
None
While in school, did you ever have an Individualized Education
Program or IEP (special education)?
YES NO
Have you ever been convicted of a felony? Yes
Details:
Probation Officer:
Phone #
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No
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 Check here if no work history
WORK HISTORY
If currently working how many hours per week do you work?
Hourly Wage:
List current or last job first. If you run out of space you may continue on the back side of this sheet.
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
Name of Employer:
Address:
Job Duties:
Title of Position Held:
Dates of Employment: From:
To:
Mo/Yr
Mo/Yr
Reason for leaving:
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DISABILITY (Check all that apply)
What is the primary medical condition, injury, physical/mental impairment or disability that limits your ability to work?
When did these impairments/disabilities begin?
Month / Year
AIDS/HIVDeaf - Blind
Alcohol or Other Drug Disorder
Deaf or Hard of Hearing Post Paraplegia or Quadriplegic

Amputation Depression Post Traumatic Stress Disorder
Arthritis
Diabetes
Respiratory/Pulmonary/Allergies
 Attention Deficit Disorder
Epilepsy
Severe Arthritis
Autism
Fibromyalgia
Specific Learning Disability
 Back Injury
Heart Disease
Spinal Cord Injury
 Blindness or Visual Impairment
Hemophilia Stroke
 Brain Injury Hip/Knee, Other Joint
 Cancer
Dysfunction
Other

 Carpal Tunnel
Kidney Failure 
(Repetitive Use Syndrome
Mental Illness
Cerebral Palsy (CP)
Muscular Dystrophy
Unknown
Cognitive Disability
Multiple Sclerosis
Cystic Fibrosis
Myofascial Disorder
CURRENT PHYSICIAN / MEDICAL PROFESSIONAL
1.
2.
3.
Name
Type of Physician
Address
Phone/Fax Number
Name
Type of Physician
Address
Phone/Fax Number
Name
Type of Physician
Address
Phone/Fax Number
If additional space is needed please enter information on the back of this page.
HOSPITALIZATIONS
Name of Hospital:
Name of Hospital:
Address:
Address:
Reason:
Reason:
LIST OF MEDICATIONS
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CONFIDENTIAL PERSONAL INFORMATION
The Bureau of Vocational Rehabilitation is a state and federally funded agency that assists persons with disabilities in
achieving or maintaining employment. I understand that it is necessary for the Bureau to collect personal information in
connection with my rehabilitation program. I understand that such information will be collected, to the maximum extent
practicable, from me. The Bureau may only use personal information for purposes directly connected with the provision
of services and the administration of the program under which services are provided.
I understand that information is available to me when requested in writing, except where the Bureau believes such
information can reasonably be expected to cause physical or emotional harm. In this instance, the Bureau shall release
such information through a qualified medical or psychological professional or to an authorized representative. Any
information provided by me is subject to verification and review through the Social Security Administration.
I understand that my eligibility and/or provision of services may be impacted if I refuse to provide personal information
that is requested by the Bureau.
I understand that my personal information will be held confidential by the Bureau and will not be disclosed to any other
person or entity except as noted in the Information and Disclosure Form.
Section 504(A) of the Workforce Investment Act of 1998; Section 12c of the Rehabilitation Act of 1973 as Amended;
29USC711c and 721(a)(6)(A); 34CFR361.38; NRS 426.573, 426.610, 432B.220, 615.280, 615.290; 629.061
In making this application for vocational rehabilitation services, I acknowledge that:
o
Purpose of applying for services: I am applying for vocational rehabilitation services for the specific purpose of
getting and/or keeping a job.
o
Choice to proceed with services: I understand I have the freedom to choose whether or not to enter into or remain
in a rehabilitation counseling relationship and whether or not to participate in any rehabilitation assessment or
service. My counselor will review with me potential consequences of choosing not to participate in any particular
service. I may request case closure at any time.
o
Change of information: It is my responsibility to inform my counselor of any changes related to this application,
such as changes in my address, income or employment.
o
Prior written approval: BVR/BSBVI will only pay for goods and services that have been pre-authorized by my
counselor, as described in the agency's Information and Disclosure Sheet. Inclusion of a good or service on the IPE
is not considered pre-authorization. I understand that I may have to pay for goods and services for which my
counselor has not provided pre-authorization.
o
Previous Debt: I understand the agency will not pay any outstanding debt, including student loans I have incurred
prior to this case being opened or any debt incurred during this case.
o
Financial Participation: I understand that I will be asked to furnish financial information and my financial needs will
be considered in determining my participation in the cost of those vocational rehabilitation services which require
the expenditure of case service dollars. Some services are exempt from the financial participant requirement.
o
Comparable Benefits: I understand that when applicable, I will be asked to apply for and secure comparable
benefits that are available to help pay for the cost of my services. Comparable benefits may include but are not
limited to health insurance, Pell Grant, Community Agencies such as Public Mental Health Agencies, etc. Some
services are exempt from the comparable services requirement.
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o
Confidentiality: I have read and understand the agency's policies in regards to confidentiality of personal
information as described on the Information and Disclosure Sheet. I understand the limits to confidentiality and
when information may be disclosed without my written consent.
o
Risks of electronic communication: I understand the risks of electronic communication, including e-mail
communication between the agency and me, and that confidentiality cannot be assured if I elect to communicate
electronically.
o
Sharing Information with DETR and SSA: I expressly give my permission for information about me to be shared
within the Department (DETR). Rehabilitation Services will also have access to Information in my Social Security,
Disability Determination, SRS, and employment records.
o
Amending Inaccurate Information in my file: If I believe information in my record of services is inaccurate or
misleading, I may request that the Bureau of Vocational Rehabilitation amend or remove the information. If the
information is not amended or removed the request for an amendment must be documented in the record of
services.
o
Liability of State for third party actions: The state of Nevada, Nevada Department of Employment, Training &
Rehabilitation, the Rehabilitation Division and the Bureau of Vocational Rehabilitation and their officers, agents,
employees and elected and appointed officials are not responsible in any manner for damages caused to a client by
third parties, including, but not limited to vendors on an approved list maintained by the State of Nevada, Nevada
Department of Employment, Training & Rehabilitation, the Rehabilitation Division and the Bureau of Vocational
Rehabilitation and hereby specifically disclaim any liability therefore. In addition, the State of Nevada will not waive
and intends to assert available NRS chapter 41 liability in all cases.
o
Auxiliary Aids and Services: I understand Auxiliary aids and services are available if required to receive equal access
to services due to my disability. I will inform my VR counselor if auxiliary aids or services are needed.
o
Discrimination: No one will be discriminated against by Rehabilitation Services because of disability, race, religion,
sex, color, national origin, length of residency in the state, or ancestry.
o
Violence, threats, harassment, intimidation and other acts of aggression and disruptive behavior will not be
tolerated and may result in case closure and, when warranted, filing of criminal charges. Acts of aggression can
include oral or written statements, gestures, or expressions that communicate a direct or indirect threat of physical
or mental harm or, indirect acts such as damage to personal property.
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ACKNOWLEDGEMENT OF ACCEPTANCE
Please place your initials beside each title of the document you have received.
_____ I have been provided the agency’s Information and Disclosure Sheet and informed about the protection, use and
release of personal information and the conditions under which my personal information may be released without
my written consent.
_____ I have been informed regarding the risks of electronic communication. I agree to the exchange of information
regarding myself through the following methods (initial all that apply):
_____ok to email
_____do not communicate with me through e-mail
_____telephone - OK to leave detailed message
_____telephone - leave only message to return call
_____telephone - do not leave a message
_____OK to use facsimile to transmit information
_____Only hand deliver or mail information regarding me
_____Other _______________________________________________________________________
_____ I have been informed of my opportunity for review of decisions made by my Rehabilitation Counselor regarding my
application, eligibility and the furnishing or denial of service if I do not agree with the decision.
_____ I have been informed of the Client Assistance Program and have been provided a copy of the steps I need to take
concerning communication and formal appeal.
_____ I have been informed of and have been provided a copy of The Participant Bill of Rights.
_____ I have been informed of the professional qualifications of VR Counselors. I agree to enter into a rehabilitation
counseling relationship at this time.
Applicant Signature_______________________________________________________Date________________
Parent/Guardian/Legal Rep Signature ________________________________________Date________________
Signature of Individual who filled out application if different from above
________________________________________________________
Parent/Guardian/or Representative's Address
____________________________________________________________ Telephone Number______________
Email address__________________________________________________
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