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.

You are not alone! We are here to help!
First Name *
Last Name *
State *
City *
Zip Code *
Email address *
Phone number *
If you do not have one then provide a family members or answer by saying "I do not have one."
Is your age between 18 and 64 years? *
Do you receive monthly Social Security Disability (SSDI) cash benefits? *
If you answered YES to receiving SSDI cash benefits, approximately when did you start receiving them?
Clear selection
Do you receive monthly Supplemental Security Income (SSI) cash benefits? *
If you answered YES to receiving SSI cash benefits, approximately when did you start receiving them?
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.
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.
Please describe your medical condition and or disability *
What is your current employment status? *
(Optional) If you are currently employed, when did you start your job?
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(Optional) If you are currently employed, are you making over $1220 per month?
Clear selection
(Optional) Besides your current job have you worked at other jobs since you started getting your Social Security cash benefits?
Clear selection
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