Ticket to Work Intake Form
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Basic Contact Information
First Name
*
Last Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Way to Reach You
*
Please Select
Phone
Email
Text Message
City
*
County
*
Please Select
Alameda
Contra Costa
Fresno
Kern
Los Angeles
Orange
Riverside
Sacramento
San Bernardino
San Diego
San Francisco
Santa Clara
Other
Benefit Status
Do you currently receive SSI or SSDI?
*
Please Select
SSI
SSDI
Both
Neither
Prefer not to say
Have you used your Ticket to Work before?
*
Please Select
Yes
No
Not sure
Employment Goals
Are you currently working with another Employment Network or VR?
Please Select
Yes
No
Unsure
Are you currently employed?
*
Please Select
Yes
No
Part-time
Seasonal
Type of work you are interested in
*
Office/Administrative
Customer Service
Retail
Healthcare
Education
Technology
Skilled Trades
Remote/Work from Home
Other
Highest level of education
Please Select
Less than high school
High school diploma or GED
Some college
Associate degree
Bachelor's degree
Graduate degree
Other
Do you have any work experience?
Please Select
Yes
No
Limited
Unsure
Disability & Support Information
Do you have a disability that affects your ability to work?
*
Please Select
Yes
No
Prefer not to say
Are you currently connected with Florida DVR?
Please Select
Yes
No
Not sure
Do you have a support coordinator or case manager?
Please Select
Yes
No
Not sure
Barriers to employment
Consent & Privacy
Electronic Signature
*
Submit
Submit
Should be Empty: