INTAKE FOR VOCATIONAL AND EMPLOYMENT SERVICES

INTAKE FOR VOCATIONAL AND EMPLOYMENT SERVICES

Michigan Department Labor and Economic Opportunity Michigan Rehabilitation Services
- Intake is only to be provided to MRS customers in Application status.
- If this Intake form is used to collect customer information, the form shall be maintained in the hard copy case record.
Customer Information
Name*

First NameMiddle NameLast Name
Mailing Address*
City*
State*
Zip Code*
Education Information

	Yes	No
Is applicant a high school graduate or have a GED?
Did applicant attend Adult Education?
Was or is applicant in special education classes while in school?
Does applicant have an Individualized Education Program (IEP)?
Does applicant have a 504 Plan?
Was applicant involved in the school's transition program?

If applicant is still in school, please provide the school name and location.
Name of School
Location
Location of School
What is the highest level of education completed and the date completed?
Highest form of education completed?*
Date completed?*

MonthDayYear
Date
If applicant is currently attending school, what is the expected Date of Graduation?

MonthDayYear
Date

Type a question*

	Grade Level Completed	Date Completed:
Elementary School (grades 1-8) includes homeschooled
High School (grades 9-12) includes homeschooled
GED
Certificate of Completion or Certificate of Attendance (Special Ed.)
Vocational/Technical Certificate or License
Some College, no degree or certificate
Associate's Degree
Bachelor's Degree
Master's Degree
Any Degree above Master's (Ph.D., Ed.D., J.D.)

Customer Name*

If applicant attended any college/trade school or other trainings, please provide the following information:

	School Name	Begin Date	End Date	Degree/Certification or area of study
1.
2.
3.
4

What credentials have been attained by the applicant?
Is applicant currently in default on any prior student loans?*

YesNo
Employment Information
What is applicant’s Employment Status?*

WorkingNot Working
What are applicant’s job interests and what services are being requested by applicant from MRS? Note: If applicant is looking for an accommodation, have they talked to their employer?

Is applicant receiving one of the following benefits:*

	Yes	No	Not Sure
Worker's Compensation
Auto No-Fault Wage Loss
Auto No-Fault Medical Benefits/Coverage
Long-Term Disability (Not SSI or SSDI)

Does applicant have child care needs?*

YesNo
What type of transportation does applicant use?*

Own CarBusOther
Has applicant ever been convicted of a felony or misdemeanor?*

YesNo
Are there limits on the kinds of jobs applicant can do or where applicant can work due to a felony or misdemeanor conviction or other legal issues?*

YesNo
Describe
Work History including Volunteer Work (approximate dates and earnings are needed) Please list current or more recent job FIRST. If more room is needed, add additional pages.

Job 1 – most recent
Employer*
Job title*
Address*
Phone Number*
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Customer Name*
Job Duties*
Was this seasonal employment?*

YesNo
If yes, when did applicant work (example: 6/yyyy-9/yyyy)*
Number of Hours Worked*
Number of Hours Worked*

DailyWeeklyMonthlyYearly
Last Salary/Pay Rate*
Reason for Leaving*
Job 2
Employer
Job title
Address
Phone Number
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Job Duties
Was this seasonal employment?

YesNo
If yes, when did applicant work (example: 6/yyyy-9/yyyy)
Number of Hours Worked
Number of Hours Worked

DailyWeeklyMonthlyYearly
Last Salary/Pay Rate
Reason for Leaving
Disability Related Information
Who is providing applicant’s treatment and what is provider’s address? (Name of Physician, Therapist, Case Manager, etc) – If more room is needed, please add additional pages.*
Customer Name*

	Yes	No
Has applicant ever been treated or hospitalized because of their disability?
Is applicant currently receiving disability related treatment?
Has applicant received disability related treatment in the past?
Is applicant currently taking any medications?

Other agencies and organizations applicant is currently involved with

Please list all other agencies and organizations that applicant is currently involved with such as: Earn and Learn Program, Shifting Gears and Moving Pathways Forward, GED program, Prisoners Returning to the Workforce, WIOA Dislocated Worker, Job Corps operated through the ISD, Michigan Works!, Summer Youth Employment Program for Foster Youth, Jobs for Michigan’s Graduates, Workforce Recruitment Program, Youth Build.

	Name of agency	Contact Person	Phone Number
1.
2.
3.
4.

Alternate Contacts (Examples: Family, Friends, Legal Guardian, Probation Officer, etc.)
Name of First Contact*
Relationship*
Phone*
Ext.
Phone Type:*

VoiceTTYFaxCellTextVideo Phone
Name of Second Contact*
Relationship*
Phone*
Ext.
Phone Type:*

VoiceTTYFaxCellTextVideo Phone
Should be Empty:

INTAKE FOR VOCATIONAL AND EMPLOYMENT SERVICES

Customer Information

Education Information

Employment Information

Job 2

Disability Related Information