For CCP Office Use Only:
Date Application Received:Accepted or Denied:
DD 214 Received: ___yes ___no
New Start for Student Veterans
Application for Enhanced Services
Directions: Please complete application and fax to (970) 491-3307, ATTN: New Start; or email application to . The New Start Team will contact the applicant regarding application status.
Date:
Application Information: (Please check all that apply.)
Incoming CSU Student DVR Client Attending school on GI Bill
Enrolled CSU Student VA Medical Client VA/VR Client
Service Connected Disability FRCC student with plans to enroll at CSU
(Date planning to enroll at CSU )
Please complete the following as applicable:
VA/VR Counselor: Phone Email
VA Medical Doctor/Counselor: Phone Email
Mental Health Counselor: Phone Email
Workforce Ctr. Counselor: Phone Email
DVR Counselor: Phone Email
CSU RDS Counselor Phone Email
I. INDIVIDUAL DATA:
Applicant Name: CSU ID # (if applicable)
Date of Birth: Age: Gender:
E-mail:
Address:
Telephone: (Cell) ______(Work/Other)
Best way to contact: ___phone ___e-mail ___letter text message
II. MILITARY SERVICE DATA:
Branch of Service: _____ Army _____ Navy _____ Marine Corps _____ Air Force _____ Coast Guard
_____ Active Duty _____ National Guard _____ Reserves
Dates of Service: ______to ______Post-9/11: _____ Yes _____ No
Deployed: _____ Yes _____ No If Yes, Where?______When______
III. Referring Counselor/Individual:
If not referenced above, please provide contact information: Phone Email
IV. BRIEF DESCRIPTION OF INJURY/DISABILITY:
V. COLLEGE MAJOR: YEAR IN COLLEGE:
VI. CAREER INTERESTS AND GOALS:
Services are provided at no cost for incoming or enrolled CSU student veterans and military personnel who are experiencing challenges related to concussion, brain injury, PTSD, and/or physical disability.
VII. ANTICIPATED SUPPORT NEEDS:
Compensatory Skills for Memory Challenges Self-Advocacy Skill Development
Time Management Organizational Skills
Study Skills Stress Management
Academic Accommodations Assistive Technology
Adaptive Equipment Internship Assistance
Career Exploration Job Development
Recreation Community access support
Other Financial/Benefit Awareness and Planning