Jefferson County - WV Region 7 The Jacks

Basic Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City 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

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)

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By 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 Evaluation

Please complete the following questionnaire so we can better service your needs!

Do you have a Disability?(Required)

Yes

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

Would you like Information on The West Virginia Department of Rehabilitation Services, Programs, and/or Resources?(Required)

Yes

Are you currently receiving unemployment benefits?(Required)

Yes

Are you a veteran or military spouse?(Required)

Yes

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

Are you between ages 14 to 24?(Required)

Yes

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

Do you have reliable transportation?(Required)

Yes

Do you have a valid Driver's License?(Required)

Yes

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

WorkforceWV Jefferson County Referral Services

Welcome!

Basic Information

Services and Resource Evaluation