CWS Inquiry Form

	Date*
	mm/dd/yyyy

	Job Seeker's Name*

	Name of person completing this form

	Date of Birth*
	mm/dd/yyyy

	Address

	County of Residence

	Preferred Phone number*

	Secondary Phone number 2

	Email*

	Primary Disability

	Other Disability

	Medications

	Drug/ Alcohol History

	Registered with Bureau of Autism Services? If so, list status and Supports Coordinator

	Registered with The Office of Intellectual Disabilities? If so, list status and Supports Coordinator

	Are you currently receiving funding through any waivers? If so, which waiver?

	Registered with OVR? If so, list counselor.

	Counseling Info

	Job Seeker Residential Information (e.g., residential group home, with family member, on own)

	Any other support staff and/or family support

	Receive SSI/SSDI

	Interested in Benefits Counseling?
	--None--YesNoMaybe

	Legal to work in U.S.
	--None--Yes No

	Criminal Background
	--None--Yes No

	Transportation Considerations

	Education

	Past Employment

	Type of Job Desired

	Strengths/Weaknesses

	Availability to Work

	Desired Work Location

	How did you hear about our program?
	How did you hear about our program? Advertisement Alumni Event Friend or Family Member Mailing Open House Event Resource Fair Social Media Website Service Coordinator Organization The Bureau of Autism Services Office of Vocational Rehabilitation Vanguard School or VFES Professional Other, please specify