WorkforceWV Jefferson County Referral Services Welcome! Step 1 of 13 7% Basic InformationName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County of Residence(Required) Jefferson Phone(Required)Email(Required) Enter Email Confirm Email How would you prefer we contact you?(Required) Call Text Email Other How did you hear about us?(Required) Walk-in Radio/TV Bus/Billboard Social Media (i.e. Facebook) Magazine, Newspaper or Journal Through a Friend/Family Another Organization Please list other Organization(Required) Consent(Required) I agreeBy checking “I agree” you are authorizing Region VII Workforce Development/WorkforceWV to disseminate the information provided for referral purposes only. Your information will not be used for the marketing or soliciting of any products or services not affiliated with WorkforceWV referrals/resource. *Message and Data Rates may apply. Services and Resource EvaluationPlease complete the following questionnaire so we can better service your needs! Do you have a Disability?(Required) Yes No I decline to answer Who is eligible for DRS services? Individuals receiving SSI and SSKI; any individual with a diagnosed mental or physical health condition; anyone currently working – but is in danger of losing their job due to a mental or physical impairment; and/or high school students receiving services under and Individualized Education Plan (IEP) or a 504 Plan.Are you an Active Client of West Virginia Division of Rehabilitation Services (DRS)?(Required) Yes No Would you like Information on The West Virginia Department of Rehabilitation Services, Programs, and/or Resources?(Required) Yes No Are you currently receiving unemployment benefits?(Required) Yes No Are you a veteran or military spouse?(Required) Yes No Do you need assistance with any of the following?(Required) Employment / Job Leads / On the Job Training (OJT) / Job Readiness Training Family & Child Services / Healthcare Food / Food Stamps / Financial Assistance / Housing Assistance High School Equivalency or High School Diploma Connecting to Veteran Organization Are you age 55 or older Substance Abuse / Addiction Services Please select all that apply Are you or someone in your household receiving any one of the following benefits: Supplemental Nutritional Assistance Program (SNAP); Temporary Assistance for Needy Families (TANF); Supplemental Security Income (SSI)?(Required) Yes No Are you between ages 14 to 24?(Required) Yes No Have you performed seasonal agricultural work (farm/orchard/chicken house) that accounted for at least 50% of your income (at least $800) or 50% of your time employed (at least 25 days) in 12 out of the most recent 24 months?(Required) Yes No Do you have reliable transportation?(Required) Yes No Do you have a valid Driver's License?(Required) Yes No How would you describe your current living situation?(Required) Stable Scheduled Eviction Homeless Living with Family/Friends Other If other, please describe.(Required) Do you have a High School Diploma or GED/High School Equivalency Diploma?(Required) Yes No Δ
