State of Wyoming
Department of Workforce Services
Office of the Director
5221 Yellowstone Rd.
Elizabeth Gagen, J.D.
Mark Gordon Cheyenne, Wyoming 82009 Director
Governor 307.777.7364 ▪ Fax: 307.777.3759 Jason Wolfe
dws.wyo.gov Deputy Director
Thank you for asking about Vocational Rehabilitation Services.
We appreciate your interest in our program.
This application must be filled out completely prior to your appointment.
When you come to your appointment please bring the following:
1. Your fully completed application. Do not leave any blanks.
2. A list of medications you are taking.
3. The names and addresses of physicians, mental health therapists, and/or other
professionals you may be seeing or have seen.
4. Medical records and documentation from the above professionals.
5. Documentation of SSI/SSDI, benefits received or denial letter.
If you are not able to keep the appointment you have been given, please call us at
307-777-7364 to let us know.
Your initial appointment has been scheduled with:
VR:_________________________________________________
Date:________________________________Time:________________________
As public servants, we work hard every day to help ensure
safe and fair workplaces with qualified workers
Department of Workforce
Services
Application Worksheet
Applicant Information
Full Name:
Last First M.I. Preferred name
Social Security Date of
Number Birth:
Address:
Street Address Apartment/Unit #
City State ZIP Code
Mailing
Address:
Street Address Apartment/Unit #
City State ZIP Code
Email
Phone: Address:
Alternate Contact: Phone:
Do you have a Legal Guardian? Yes No Name: ___________________________
Phone Number of Guardian: ___________________________ Do you live with Guardian? Yes No
Gender: Male Female Non-Binary Prefer not to answer
Race: American Indian African American/Black Caucasian Asian Native Hawaiian/PI Hispanic Descendent
Preferred Language?
Who referred you to DVR?
What are your expectations from the agency?
What can DVR assist you with returning to, or maintaining employment?
What services if any did you receive in the past or are currently receiving? Did these lead to work?
Effective 7/1/2024
Financial Information
How are you currently supporting yourself? Please indicate monthly/weekly or yearly
SSI Aged $ SSI Blind $ SSI Disabled $ SSDI $ Employment $
Friends/Fa $ TANF $ General Assistance $ VA Benefits $
mily
Unemployment $ Workers Comp $ Other Public Support $ SNAP $
Insurance
Do you have Medical Insurance from one of these sources?
Medicaid Medicare Private Insurance through other means Public Insurance from other sources
State or Federal Affordable Care Act Exchange Private Medical insurance through own employment
Not Yet Eligible for Insurance through current employment No Medical Insurance at this time
Marital Status Single/Never Married Married Divorced Separated Widowed
How many dependents, if any, do you have? ____
Are you responsible for one or more dependents under the age of 18? Yes No
Do you return to the same residence every night? Yes No
Current Living Private Residence/Family Group Home Mental Health Facility Homeless/Shelter
Arrangement:
Rehabilitation Facility Correctional Facility Halfway House Facility Substance Abuse Center
Have you ever been involved in any
stage of the criminal justice process for
committing a status offense or
delinquent act? YES NO
If Yes, explain:___________________________________________________
_______________________________________________________________
Do you have a record of arrest or YES NO
conviction? If Yes, explain:___________________________________________________
_______________________________________________________________
YES NO
Are you a veteran?
Effective 7/1/2024
2
Disability Information
What disability/impairment do you have that interferes with your ability to work?
Education
Are you currently enrolled? If so, where?
High School Highest Grade Completed Did you graduate? Year Graduated
Did you receive services Yes No Please list any other
under an IEP or 504 Plan? accommodations you
received:
College Major Did you graduate? Degree Type
Yes No
Dates attended TO
College Major Did you graduate? Degree Type
Yes No
Dates attended TO
Please list any other trainings you have completed:
Please rate yourself on the following skills with an X in the corresponding box:
Limited ability: Low ability:
Proficient/Functional Skills not at a functional level at/below 8th-grade level
Speaking in English
Writing in English
Reading in English
Understanding in English
Computing skills and
problem-solving
Do you live in a family or community environment where a language other than English is dominant? Yes No
Do you possess attitudes, beliefs, customs, or practices that influence a way of thinking, acting, or working that
may serve as a hindrance to employment? Yes No
Are you a military spouse who is affected by relocation and is finding difficulty in obtaining or upgrading
employment? Yes No
Effective 7/1/2024
3
Are you a homemaker who used to rely on the income of a family member and now are not supported by them due
to divorce, separation, or death? Yes No
Are you engaged in agriculture or fish farming for the past 12 months? Yes No
Have you experienced any of the following?
Laid Off Notice of Termination Previously self-employed but had to close business? Yes No
Previous Employment
Are you currently employed? Yes No
What, if any, disability accommodations provided by your previous employer(s)?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
From: To: Reason for Leaving:
Wage comparable to others in the job?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
From: To: Reason for Leaving:
Wage comparable to others in the job?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Effective 7/1/2024
4
Responsibilities:
From: To: Reason for Leaving:
Wage comparable to others in the job?
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary:$ Ending Salary:$
Responsibilities:
From: To: Reason for Leaving:
Wage Comparable to others in that job?
WIOA Program Involvement
Please circle any services listed below you were/are involved with:
American Job Center Adult Education Job Corps
Previous Vocational Rehabilitation services Youth Build (Please add grant number)
Wagner-Peyser Program for assistance with WIOA-Youth program while in school or out of
job search or job referral and placement school to prepare for training and secure
opportunities
Effective 7/1/2024
5
Client Medical History
Do you have problems with? (please circle if you have these symptoms)
Head & Neck CNS
Frequent Headaches Dizziness Neuritis Loss of Balance
Visual Impairment Double Vision Fainting Spells Convulsions
Hearing Impairment Draining Ears Paralysis Nervousness
Sinus Trouble Teeth
Tongue
GI Cardio-Respiratory
Blood in Stools or Diarrhea Chronic/Frequent Chest Pains
Tarry Stools Colds
Vomiting Blood Stomach Pains Cough up Blood Night Sweats
Frequent Indigestion Constipation Shortness of Breath Fluttering of the Heart
Swelling of feet/ankles
G.U. Musculo-Skeletal
Frequent Kidney Frequency of Weakness of Deformity of back,
Infections Urination arms/legs arms, or legs
Pain in Urination Kidney Stones Arthritis Muscle Disease
Blood in Urine
Serious Illness
Cancer Heart Trouble Strokes Meningitis
Gallbladder Disease Kidney Disease Lung Disease/Asthma Diabetes
Polio Ulcers Jaundice Bone or Joint Disease
If you have broken any bones – what bones and when?
If you have had any operations or serious injuries – what and when?
If you have been hospitalized for any illness, please list.
Please list all medications that you are taking regularly:
If you have been treated for any alcoholism or drug dependence – when and where?
Effective 7/1/2024
6
State of Wyoming
Department of Workforce Services
Department of Vocational Rehabilitation
3817 Beech Street Suite 100
Mark Gordon Laramie, Wyoming 82070
Governor
307-745-3160 ▪ Fax: 307-721-3110 Elizabeth Gagen, J.D.
Director
www.wyomingworkforce.org
CLIENT EXPECTATIONS
(effective 3/2023)
As a State of Wyoming DVR client, you are expected to treat DVR staff and other people involved in
your case with respect and courtesy. DVR promotes a safe and secure environment and does not tolerate
aggressive or threatening behaviors (verbally or physical). Staff, clients, volunteers, and the public will
not have to tolerate such behavior and said behaviors will be reported immediately. Zero tolerance of
aggressive or threatening behavior extends to all DVR locations, including offsite, home, and
community settings. These expectations are to be upheld by the client and/or someone associated with
the client (e.g., a partner, relative, advocate etc.).
Manner
Always maintain a polite and professional manner during any exchange with the agency and all others
involved in your case, just as you would in an employment setting, educational setting, or any other
professional capacity. This includes all in-person meetings and other correspondence (email, fax, mail,
etc.) that you participate in throughout the duration of your case.
Empathy
As our program serves high volumes of clientele it is important to understand that your rehabilitative
needs are always at the forefront of our mind. Please give our vocational rehabilitation staff, including
your VR Counselor, some understanding and patience as they work diligently on your DVR case.
Empathy and understanding towards one another are best practiced mutually.
Honesty
Be honest with the DVR agency. This will help with your vocational rehabilitation process.
Warning
If you repeatedly inappropriately touch, use foul language, and/or threaten any staff, clients, or
community partners, you will be given a total of three warnings before your services will be terminated.
The first warning will be given verbally and documented in your case file, the second will be written, the
third will be written and result in your case being reviewed for closure by agency administration. If your
case is closed, a case closure letter will be mailed.
Collaborating to support a thriving workforce and economy
Questions or Concerns
If you have questions or concerns about how your case is handled you are welcome to contact one or
both of the following numbers below:
Regional Manager
Jessica McComb 307-745-3160
Protection and Advocacy Client Assistant Program
7344 Stockman Street, Cheyenne WY 82609 and/or 307-632-3497.
NOTE: By signing this form, you acknowledge your understanding of the information, client
expectations, and informed consent.
Client Signature: _________________________________________________ Date:________________
Client Printed Name: __________________________________________________________________
Guardian Signature:_______________________________________________Date:________________
Guardian Printed Name: _______________________________________________________________
VR Counselor Signature:__________________________________________ Date:________________
Collaborating to support a thriving workforce and economy
DIVISION OF VOCATIONAL REHABILITATION
OVERVIEW OF SERVICES
Welcome to the Division of Vocational Rehabilitation! We will do our best to help you
gain employment that is within your capabilities and interests.
People often come to Vocational Rehabilitation (VR) knowing very little about what the
Agency does or they have heard stories about what we can and can’t do which are
frequently incorrect or inaccurate. This brief overview of services is intended to prevent
misunderstandings. The “DVR Client’s Guide to Employment Services for People with
Disabilities” booklet will help you understand the vocational rehabilitation process and
should also be read.
Please let your counselor and his/her assistant know what your needs and expectations
of VR are, so that we can address them to your satisfaction. VR will work with you as
an individual and services will be provided based on your unique vocational
rehabilitation needs.
The following statements are given to you to help you understand what VR tries to do
and what VR can’t do.
o You can expect to be treated courteously, professionally and with respect.
o VR’s intention is to give you the best vocational rehabilitation services possible.
o VR’s goal is to help you become, or remain, as independent as possible by
obtaining and maintaining employment.
o VR budgets are limited, therefore:
Your counselor will ask you to contribute as much as possible financially
(this also supports the concept of maintaining independence).
Only services that are necessary to help you obtain or maintain
employment will be provided.
You may be asked to help locate other sources of funding such as
insurance, Social Security Disability Income, Social Security Income,
Community Service Organizations and school grants.
o VR’s philosophy is that consumer involvement in their rehabilitation is critical; you
are expected to be a full partner in decision making, working towards your
vocational rehabilitation goal and sharing costs if possible.
o Everyone is treated as an individual. Services are provided based on the
individual’s rehabilitation needs and circumstances. As a result, rehabilitation
services provided to one individual may not be provided to another individual.
o You have the right to appeal decisions in your case. Tell your counselor if you
disagree with a decision. The counselor will help you. You have appeal rights
and can also contact the Client Assistance Program (CAP) at 1-800-821-3091.
Additional information about CAP is provided in this information packet.
CLIENT RESPONSIBILITIES
To participate in developing your Vocational Rehabilitation Plan
To follow through with the responsibilities in your Plan
To immediately tell your Counselor about anything that may affect your
vocational rehabilitation plan or your return to work
To keep all appointments and to call to re-schedule if you are unable to
keep it
To treat all VR staff with courtesy
o VOCATIONAL REHABILITATION IS NOT AN INSURANCE COMPANY.
o VR must try to use other resources before using its funding. VR will not provide
funds for medication, or mental and physical restoration services unless
absolutely necessary for your vocational rehabilitation, and then only for a short
time period.
o VOCATIONAL REHABILITATION IS NOT A SCHOLARSHIP FUND.
o College students must apply for available financial aid such as all Federal, State
and local scholarships.
o Services are contingent upon funds being available.
o All spending in your vocational rehabilitation process must be authorized
BEFORE the service is provided. Never assume VR will pay for anything. Make
sure the service is in your Individualized Plan of Employment (IPE).
o If you have questions, please ask your Counselor or an Assistant.
o VR will work with you to research all available funding to reach your employment
goal.
WHAT YOU CAN DO
REMEMBER THAT THE COUNSELOR/CONSUMER RELATIONSHIP
IS BASED ON A PARTNERSHIP
1. You must communicate honestly and in a timely manner with your Counselor.
This includes making a commitment to the VR process by meeting your
responsibilities, i.e., keeping appointments, discussing potential changes in plans
etc., with your Counselor. Follow through on your Individualized Plan of
Employment (IPE). Keep in contact regularly with your Counselor.
2. Remember this is an eligibility program, not an entitlement program. This means
you have rights in the process if you are eligible, but you are not entitled (do not
have a right to) VR services.
3. Please be patient. Remember that the counselor has other individuals on their
caseload and will assist you as quickly as they can. Please be assertive, not
aggressive.
ADDITIONAL INFORMATION
FOR WORKER’S COMPENSATION (WC) REFERRALS
Worker’s Compensation/Vocational Rehabilitation cases can last up to four (4) years
and up to $30,000 according to the law. However, these are the maximum amounts
and you are not entitled to either.
VR is responsible for getting you back to work as quickly and cost effectively as
possible.
Workers Compensation may provide a stipend, at VR’s discretion, while you are in an
approved training program. The stipend is dependent on total cooperation with the
rehabilitation plan and full time involvement in a training program.
PROTECTION & ADVOCACY SYSTEM, INC.
Client Assistance Program (CAP)
7344 Stockman Court
Cheyenne, WY 82009
307-638-7668 Voice/TDD
1-800-821-3091 (Assistance Requests Only)
307-638-0815 FAX
E-mail: [email protected]
Website: www.wypanda.com
The protection and advocacy system for the state of Wyoming.
This document is not intended to provide legal advice.
It is not a substitute for consulting with an attorney of your choice.
CLIENTS’ RIGHTS
1. Application. You have the right to apply or reapply for rehabilitation services.
2. Eligibility. You have the right to an evaluation to determine if you are eligible for
vocational rehabilitation services. You are to be notified of the eligibility decision
within 60 days of your signed statement of application. However, there are times
the necessary information cannot be obtained within the stated time through no
fault of your counselor or yourself. You and your counselor will discuss available
options. If you are not eligible, you have a right to know why.
3. Participate in Program Planning. You have the right to be a participant in the
planning of your vocational goals, rehabilitation services and to choose the
service vendor.
4. Confidentiality. All information given to your counselor will be used only for
your rehabilitation program.
5. Case File. You have a right to see information in your file. Your counselor will
explain the exceptions. You may have a third party review your file.
6. Closure. You have a right to be consulted before your counselor closes your
case.
7. Non-Discrimination. You have the right to be provided rehabilitation services in
a non-discriminatory manner without regard to race, color, creed, sex, national
origin, or disability.
8. Client Assistance Program (CAP) Notification. You have the right to be
provided information concerning the availability of CAP.
9. Appeals Process. You have the right to access Division of Vocational
Rehabilitation’s (DVR) informal and formal appeal processes.
The first step is to submit a letter to the State Administrator of the Division of
Vocational Rehabilitation requesting to access the appeal process. The letter
should be submitted within a timely manner which starts strict deadlines for
further appeals. The Client Assistance Program personnel are available to assist
and if appropriate, represent you at any time prior to or during the appeal
process.
The informal methods cannot be used as a means to delay a more formal
hearing before an impartial hearing officer unless you and DVR jointly agree to a
delay.
The following are the informal and formal steps of DVR’s appeal process.
INFORMAL
A. Negotiate with Counselor or Area Consultant
B. Administrative Review (request in writing)
C. Mediation (request in writing)
FORMAL
A. Fair Hearing (request in writing)
B. Court
Strict time deadlines apply to your right to seek review of actions or determinations. You should consult
with an attorney or P&A regarding these deadlines. You will lose your right to review if you do not request
the review in the time required by law. See, generally, 29 U.S.C.§722(c), 34 C.F.R.§361.57 and Wyo.
Stat.§§16-3-101 et seq.
This publication was made possible by funding support from the Rehabilitation Services Administration,
U.S. Department of Education. These contents are solely the responsibility of the grantee and do not
necessarily represent the official view of the Rehabilitation Services Administration, U.S. Department of
Education.
This publication is paid 100% by federal funds and is available in alternative formats.
