NW Works' Application for Services
Please use this application if you are interested in receiving services from NW Works. This form must be completed in its entirety. If something does not apply, please select N/A. Please include a valid email address either for the individual seeking services or for a reliable point of contact for that individual.
Email address *
What is the name of the individual whom services are being sought for (the applicant)? *
Please enter the name of the individual who completed this application, if different than individual for whom services are being sought for. *
If applicant is applying for themselves, please enter N/A.
What is the applicant's birth date? *
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What is the applicant's Social Security Number? *
What is the applicant's address? *
What is the applicant's phone number? *
If you have more than one phone number, please indicate which number is preferred with an *. If applicant does not have a phone number, please list a phone number at which a reliable point of contact can be reached.
Is applicant married? *
If applicant is married, what is the applicant's spouse's name? *
If you are not married, enter N/A.
Who is the applicant's primary emergency contact? *
What is the applicant's emergency contact's relationship to the applicant? *
What is the emergency contact's address? *
What is the emergency contact's phone number? *
What is the emergency contact's email address? *
Is the applicant their own legal guardian? *
If the applicant has a legal guardian, please enter their name. *
If the applicant does not have a legal guardian, enter N/A.
If the applicant has a legal guardian, please enter their address. *
If the applicant does not have a legal guardian, enter N/A. Please note, a copy of documentation of authorized representative must be submitted with this application. Documents can be submitted by emailing feedback@nwworks.com. Please include the applicant's name in the subject line.
If the applicant has a legal guardian, please enter their phone number. *
If the applicant does not have a legal guardian, enter N/A.
What is the name of the applicant's authorized representative? (If applicable) *
If the applicant does not have an authorized representative, enter N/A. Please note, a copy of documentation of authorized representative must be submitted with this application. Documentation can be submitted by emailing a copy of the file to feedback@nwworks.com. Please include the applicant's name in the subject line.
What is the name of the applicant's DRS or CSB counselor?
Please enter N/A if this is not applicable.
Does the applicant receive any of the following? *
Required
What is the name of the payee for the benefits selected? *
If the applicant does not receive benefits, please enter N/A.
What is the applicant's primary disability? *
What is the applicant's secondary disability? *
If not applicable, please enter N/A.
Does the applicant have any other medical conditions? If yes, please list them here. *
If not, please enter N/A
Does the applicant have any physical limitations or restrictions? If yes, please enter them below. *
If not, please enter N/A.
Does the applicant have seizures? *
If you answered yes to the last question, please list the date of the applicant's last seizure.
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Does the applicant have any allergies? *
If yes, please list them here and indicate the severity. If no, please enter N/A.
Can the applicant take aspirin? *
Who is the applicant's primary physician? *
What is the applicant's primary physician's phone number? *
What is the applicant's primary physician's address? *
Does the applicant have a secondary physician? If yes, enter their name, phone number, and address below. *
If no, enter N/A.
Does the applicant have medical insurance? *
If yes, please enter the name of the insurance company. *
If no, enter N/A.
If the applicant has medical insurance, please enter the group number. *
If the applicant does not have insurance, enter N/A.
If the applicant has medical insurance, please enter the policy number. *
If the applicant does not have insurance, enter N/A.
What is the applicant's Medicaid number? *
If the applicant does not have a Medicaid number, enter N/A.
What is the applicant's Medicare number? *
If the applicant does not have a Medicare number, enter N/A.
What was the date of the applicant's most recent Hepatitis B test? *
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What was the date of the applicant's last Tetanus vaccination? *
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What was the date of the applicant's last physical? *
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What is the name of the last school the applicant attended? *
What was the highest grade the applicant completed? *
Please list any vocational training the applicant has received. *
Please list the name of the applicant's last employer. *
If the applicant has not previously been employed, please enter N/A.
Please list the address of the applicant's last employer. *
If the applicant has not previously been employed, please enter N/A.
Please list the phone number of the applicant's last employer. *
If the applicant has not previously been employed, please enter N/A.
What is the reason for leaving the applicant's last place of employment? *
If the applicant has not previously been employed, please enter N/A.
How will the applicant commute to NW Works? *
Does the applicant authorize the exchange of confidential information to be exchanged for the purpose of: *
NW Works requires the applicant's consent to exchange information between Agencies and Agents to effectively provide and/or coordinate services, programs, and or benefits.
Required
The following Agencies/Agents are authorized to exchange the applicant's information orally, written and/or facsimile/computer generated data with NW Works: **should this be rephrased as "NW Works is authorized to share information with the following agencies"? *
Please select all that apply.
Required
The following confidential information may be shared: *
Required
I can rescind this consent or any portion at any time by notifying the appropriate agent(s), agency or agencies. Upon notification, those notified will cease to disclose my confidential information immediately. I have the right at any time to know what information has been disclosed, why, when whom, and for what purpose. All agencies/agents will respond upon request. All agencies/agents will accept a copy of this form as a valid consent to disclose information as determined. *
Required
Electronic Signature: Please sign your name to submit your application. *
By entering your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. If you are filing this application on behalf of someone else, please enter the name of the individual seeking services here.
Electronic Signature: Parent/Guardian/Authorized Representative *
By entering your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. If you are filing this application on behalf of someone else, please enter your name here. If you are the individual seeking services for yourself, please enter N/A.
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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