Menominee Vocational Rehabilitation Program

Services are rendered only after you are determined eligible and have entered into the Individualized Plan of Employment. This Process may take up to 90 days.*

Initial

Full Name*

First NameMiddle NameLast NameSuffix

Date of Birth*

Date

What is your gender?

Address*

Physical Address

Mailing Address

CityState / Province

Postal / Zip Code

Phone Number*

Message Phone:

Please enter a valid phone number.

Do you give Menominee Vocational Rehabilitation permission to leave a message this number

Email Address

example@example.com

Check preferred method of contact:

Tribal Affiliation: * Enrollment Number: Type a label

Are you a Veteran of the U.S. Armed Services?*

YesNo

If yes, what branch?

Have you applied for VR services in the past?

YesNo

If yes, what year?

Have you received State VR in the past?

YesNo

If yes, what year?

Have you received Tribal VR in the past?

YesNo

If yes, what year?

Disability (check all that apply)*

Please state disability if not listed above:

How does you disability impede your ability to attain, maintain and retain employment?*

What services will you be asking for from CMN MVR?*

List the kind of jobs you would like to have:*

Do you reside on the Menominee Indian Reservation or within 30-miles of the Reservation?*

YesNo

Does your Disability make it hard for you to get or keep a job?*

YesNo

Do you have the time and interest to make a plan and complete tasks needed for getting and keeping a job?*

YesNo

Have you been told that you must apply for VR services to keep receiving services from another program (please keep in mind that MVR is a voluntary program)*

YesNo

Are you TRULY ready to prepare to secure, retain, advance in, or regain employment?*

YesNo

My disability makes it difficult to get ready,go to work, or take care of myself while working*

YesNo

My disability makes it difficult for me tocommunicate (in the way I need to communicate at work)*

YesNo

My disability makes it difficult for me to get to and from places, (especially to and from work)*

YesNo

My disability makes it difficult for me to get to and from places, (especially to and from work)*

YesNo

My disability makes it difficult for me to get along with others at work*

YesNo

My disability makes it difficult for me to follow through with plans (This is sometimes the result of emotional problems, depression, or other mental illnesses.)*

YesNo

My disability makes it difficult for me to work full-time or perform all the physical duties*

YesNo

My disability caused me to have a poor work record*

YesNo

My disability made it difficult for me to learn new job skills*

YesNo

I lost a job because I became disabled or was injured*

YesNo

The College of Menominee Nation Menominee Vocational Rehabilitation Program offers vocational rehabilitation services to individuals who meet the following requirements:

Must be an Enrolled member of a State or Federally Recognized Tribe or an Alaskan Native.
Reside within the defined service area of the CMN-MVR (30 miles of Menominee Reservation Boarders)
Must have a physical or mental impairment that can be documented
The impairment must constitute or result in a substantial impediment to employment and;
You can “reasonably expect to benefit”, in terms of employment, from the vocational rehabilitation service received.

Upon completion of the referral process, the CMN MVR Counselor will conduct an intake interview to assist in determining eligibility. You will be asked to sign a release of information permitting your healthcare provider to release your disability information directly to CMN MVR. Services are rendered only after you are determined eligible and have entered into the rehabilitation phase of your program. This process may take up to 90 days.

I understand the requirements for eligibility in the College of Menominee Nation Menominee Vocational Rehabilitation Program. I will participate in anyway necessary to facilitate the development and implementation of my Individualized Plan for Employment (IPE).

Signature*

Today's Date*

Date