Interest Form for Rehabilitation Services

We are excited you are interested in learning more about Vocational Rehabilitation Services (VRS). Please fill out the form below so that we can connect you with the office closest to you! A staff person will respond to you as soon as possible. Please know, in some locations we are experiencing high volumes of interest, and it may take a VRS staff person longer to connect with you.

Name

*First Name

*Last Name

Preferred Name

Pronoun

Address

Are you homeless?

Address 1

Address 2

City

State

Zip

County

How would you prefer to be contacted (at least one is required)?

Phone

Phone Type

Text Message

E-mail

*Please tell us the best time of day to reach you

Are you completing this form for someone else?

*Birth Date

*Primary Language

*Do you need an interpreter?

Are you: (Answering this will help us connect you with the right counselor. Many of our counselors specialize in working with specific disabilities. Please check all that apply.)
Deaf or Hard of Hearing
Enrolled in High School
Receiving Services from Medicaid Waiver (ex. CAC, CADI, DD, BI)
Receiving Services through Individual Placement Support Services (IPS)
Other

Tennessen Warning

*Privacy Notice: This notice describes how private information about you may be used and disclosed. Please review it carefully. Vocational Rehabilitation Services (VRS) is asking that you complete the form above. VRS will use this information to let you know which vocational rehabilitation (VR) services may help you and to connect you with the appropriate VRS staff for further follow-up. You don’t have to give us information about yourself, but without the information we may not be able to tell you what VR services could help you or connect you with the right VRS staff person.
The personal information you provide on this form is private and will only be shared with staff who have a need to know the information or as required by law.

By completing and submitting this form you confirm the following:
1. You have read and understood the information provided above and you agree to supply the information requested to complete this form.

2. You understand that your information may be used as described above.

Accept Tennessen Warning
Decline Tennessen Warning