For CCP Office Use Only

For CCP Office Use Only:

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