Fill out survey to be matched with a Work Incentives Planning and Assistance (WIPA) counselor
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First Name *
Last Name *
State *
City *
Zip Code *
Email address *
Phone number *
If you do not have one then provide a family members or answer by saying "I do not have one."
Please describe your medical condition and or disability? *
Tell us about the one specific job or all of the different types of jobs you would be interested in pursuing? *
To pursue this job or jobs, do you need further training or schooling? *
Do you receive or have you received state Vocational Rehabilitation (VR) services? *
Every state has a VR program that provides services to help individuals with disabilities to prepare for, secure, regain or retain employment.
To secure a job, what have you done so far? *
Is your age between 18 and 64 years? *
Do you receive monthly Social Security Disability (SSDI) cash benefits? *
If you answered YES to receiving SSDI cash benefits, approximately when did you start receiving them?
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Do you receive monthly Supplemental Security Income (SSI) cash benefits? *
If you answered YES to receiving SSI cash benefits, approximately when did you start receiving them? *
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