Employment Services Application
Application Date
*
-
Month
-
Day
Year
Date
Individual's Name
*
First Name
Last Name
Individual's Date of Birth
*
-
Month
-
Day
Year
Date
Individual's Medicaid #
*
Ex. AB12345C
TABS ID
*
Primary Contact Phone
*
-
Area Code
Phone Number
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings (Brooklyn)
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York (Manhattan)
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond (Staten Island)
Rockland
Saint Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming
Yates
School Age?
No
Yes
School District Name
What service does the person want to receive at Springbrook?
Community Based PreVoc
Pathway to Employment
Supported Employment
Is the applicant receiving other Springbrook services?
Community Habilitation
Day Habilitation
Respite
No
Is the applicant already receiving any of these services from another agency?
*
Yes
No
Agency Name
Type of Employment Service
Pre Voc
Supported Employment
Access VR
Does the applicant have allergies?
*
Yes
No
If yes to allergies, please describe:
Does the applicant have seizures?
*
Yes
No
If yes to seizures, please describe:
Does the applicant have any need for meal time support?
Yes
No
If yes to need meal time supports, please describe:
Does the applicant have any behavioral support needs?
*
Yes
No
If yes to behavioral support needs, please describe:
If yes, please upload behavior support plans here.
Browse Files
Cancel
of
Is the applicant approved for physical interventions, such as SCIP-R? OPWDD Employment Services staff are not able to perform physical interventions, such as SCIP-R.
Yes
No
Does the applicant need assistance with medical procedures during service delivery? OPWDD Employment Services staff are not able to provide support with medical procedures.
Yes
No
If yes to need assistance with medical procedures, please describe:
What are the applicant's likes and interests
What are the applicant's dislikes and fears
Education/Training/Employment
Has the person graduated high school?
Yes
No
Does the person have any past vocational experience?
No
ETP
Access-VR
Other
Any additional training or education?
No
BOCES
Post Secondary
Other
Is the person currently employed?
No
Other
Please list past job history
Does the person have a self direction budget?
*
No
Yes
Name of their Support Broker
*
First Name
Last Name
Email of their Support Broker
*
example@example.com
Phone Number of their Support Broker
*
-
Area Code
Phone Number
What Agency is their FI?
*
Name of their FI Coordinator
*
First Name
Last Name
Email of their FI Coordinator
*
example@example.com
Phone Number of their FI Coordinator
*
-
Area Code
Phone Number
Any criminal history or pending charges?
No
Other
Does the person have a valid driver's license or non driver ID?
No
Yes, please upload.
Driver license or non-driver ID - Upload here.
Browse Files
Cancel
of
Does the person have a valid social security card?
No
Yes, please upload.
Social Security Number
*
Social security card - Upload here.
Browse Files
Cancel
of
Please upload the Life Plan, including all attachments here.
Browse Files
Cancel
of
Notes from the CCM:
Name of CCM submitting application
First Name
Last Name
Care Coordination Agency
Advance Care Alliance
Care Design
Life Plan
Person Centered Services
Prime Care Coordination
Southern Tier Connect
Tri-County Care
Email address of CCM submitting application
example@example.com
Phone Number of CCM submitting application
-
Area Code
Phone Number
Submit
HCBS Sender Email
example@example.com
Should be Empty: