Form Dhs 1277 - Service Questionnaire Page 7
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10Counselor notes (counselor see application section, page two, for benefits information):
Additional information
What services do you think you might need from Vocational Rehabilitation to be successful at assisting
you to get to or back to work? (check all that apply.)
Learn how to look for and find work
Help to decide a work goal
Learn how to work with my disability
Other
(Please explain):
What strengths or skills have you identified about yourself?
Counselor notes:
What type(s) of work are you interested in doing?
Part time-hours per week:
Full time
Not sure
What is your current level of computer skills/knowledge?
What is your source of transportation?
Bus
Car
Bike
Other
Do you possess a valid driver’s license?
Yes
No
Insurance
Yes
No
If yes, what state:
Page 7 of 10
DHS 1277 (10/2016)
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