Are you currently receiving any of the following? If yes, please list the MONTHLY amount. (Social Security Disability Insurance) Amount: $_ SSDI Assistance (Public Assistance) Amount: $_ General (Supplemental Security Income) Amount: $_ SSI disability benefits Amount: $ Veterans’ (Temporary Assistance for Needy Families) Amount: $ TANF other public support Amount: $ Any compensation Amount: $ Workers’ (Please describe)_ Do you have any of the following types To help us coordinate your services, please of medical insurance coverage? Check check any other services you are receiving. one or more: Check one or more if you are receiving the following: Medicaid  Medicare  Assistance (TANF) $ Temporary Workers’ Compensation  Assistance (GA) $ General Private insurance through employment  Stamps $ Food Insurance Company  and Family Services Children No Medical Insurance Coverage  Care Foster Other Public Insurance  Support Enforcement Child Private insurance through other means: Care Child (for example, insurance through your Protective Services Adult parents or spouse) Income Energy Assistance Low Medicaid Healthy Working Other None COMMUNICATION ACCOMMODATIONS While in school, did you ever have an print Regular Individualized Education Program or IEP Braille (special education)? language (specify) print YES NO Large What is your primary means of transportation? Have you ever been convicted of a felony? Vehicle Personal Yes No Details: Transportation Public Other Probation Officer: # ( )
Are you currently receiving any of the following? If yes, please list the MONTHLY amount. SSDI (Social Security Disability Insurance) Amount: $_ General Assistance (Public Assistance) Amount: $_ SSI (Supplemental Security Income) Amount: $_ Veterans’ disability benefits Amount: $ TANF (Temporary Assistance for Needy Families) Amount: $ Any other public support Amount: $ Workers’ compensation Amount: $ (Please describe)_ Do you have any of the following types of medical insurance coverage? Check one or more:  Medicaid  Medicare  Workers’ Compensation  Private insurance through employment  Insurance Company  No Medical Insurance Coverage  Other Public Insurance Private insurance through other means: (for example, insurance through your parents or spouse) To help us coordinate your services, please check any other services you are receiving. Check one or more if you are receiving the following: Temporary Assistance (TANF) $ General Assistance (GA) $ Food Stamps $ Children and Family Services Foster Care Child Support Enforcement Child Care Adult Protective Services Low Income Energy Assistance Medicaid Working Healthy Other None COMMUNICATION ACCOMMODATIONS Regular print Braille language (specify) Large print While in school, did you ever have an Individualized Education Program or IEP (special education)? YES NO What is your primary means of transportation? Personal Vehicle Public Transportation Other Have you ever been convicted of a felony? Yes No Details: Probation Officer: # ( )
BVR_App_Large_Print.docx