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FREE Disability Employment Benefits Mentor and Counselor
Do you have a spinal cord injury or paralysis?
Do you receive Social Security cash benefits?
Are you working or would like to start work soon?
If so, by filling out this survey you could soon be matched with a FREE disability employment benefits mentor and counselor to help navigate the working world with a disability. Your information shared throughout the survey may be shared with our partner employment network to determine participant eligibility.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
State
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Email address
*
Your answer
Phone number
*
If you do not have one then provide a family members or answer by saying "I do not have one."
Your answer
Is your age between 18 and 64 years?
*
Yes
No, I am younger than 18 years old
No, I am older than 64 years old
Other:
Do you receive monthly Social Security Disability (SSDI) cash benefits?
*
Yes
No
I am not sure
Other:
If you answered YES to receiving SSDI cash benefits, approximately when did you start receiving them?
Within the last 5 years
Between 5-10 years ago
More than 10+ years ago
I am not sure
Other:
Clear selection
Do you receive monthly Supplemental Security Income (SSI) cash benefits?
*
Yes
No
I am not sure
Other:
If you answered YES to receiving SSI cash benefits, approximately when did you start receiving them?
Within the last 5 years
Between 5-10 years ago
More than 10+ years ago
I am not sure
Other:
Clear selection
Do you receive or have you received state Vocational Rehabilitation (VR) services?
*
Every state has a VR program that provides services to help individuals with disabilities to prepare for, secure, regain or retain employment.
Yes, I am currently receiving VR services
No, but I previously received VR services
No, I have never received VR services
I am not sure
Other:
Have you ever worked with an Employment Network?
*
An Employment Network matches free employment benefit counselors to individuals with disabilities that are receiving or have recently received Social Security disability cash benefits.
Yes, I am currently receiving employment benefit counseling from an Employment Network.
Yes, but I am not happy with my current Employment Network and would like to find a new one.
No
I am not sure
Other:
Please describe your medical condition and or disability
*
Your answer
What is your current employment status?
*
I am currently employed
I am currently self-employed
I am unemployed but have a job offer and I am about to start within a few weeks
I am unemployed and I am searching for a job
I am unemployed and I am not searching for a job
Other:
(Optional) If you are currently employed, when did you start your job?
MM
/
DD
/
YYYY
(Optional) If you are currently employed, are you making over $1220 per month?
Yes
No
I am not sure
Clear selection
(Optional) Besides your current job have you worked at other jobs since you started getting your Social Security cash benefits?
No
Yes, I have worked in the past 0-2 years
Yes, I have worked in the previous 3-5 years
Yes, I have worked in the previous 5+ years
Other:
Clear selection
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