VOCATIONAL REHABILITATION COUNSELING RECORD

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I request you please complete this record to the best of your ability in advance of our meeting as

if you were applying for work. The information will be used for purposes of Vocational

Diagnostic Interviewing and Vocational Rehabilitation Counseling. Unless otherwise requested

please present these completed data sheets to me when we next meet - do not mail them to me

unless specifically requested to do so. Thank you for your anticipated cooperation.

TODAY’s DATE: _______

[PLEASE PRINT]

JOB INTERESTS - What types of job position[s] would you like to be considered for?

Name:

Address:

Code

First

Telephone:

[Area Code]

Social Security #

I

I

Beeper #:

Cellular Phone #:_______________

Fax #:____________

E-Mail._____________

1.

Are you employed now?

[]Yes

[]No Date last worked?______

Do you have a typed resume you can give me?

[]Yes

]No

3.

Have you applied for any jobs in the last 3 months?

[]Yes

]No

4.

Do you wish to return to work in the labor market?

[]Yes

]No

5. When did you last have contact with your employer or supervisor? __________________

May we contact your present employer?

[]Yes []No

[appx. datel

7.

Are you prevented from lawfully becoming employed in this country because of Visa or

Immigration status?

[] Yes [] No

8. When requested, can you provide genuine documentation establishing your identity and

eligibility to be legally employed in the United States?[] Yes [] No

Last

Middle

Number

Street

City

State

Zip

9.

On what date would you be available for work?