MassAbility Transition Services (Pre-ETS) Potentially Eligible Intake & Service Plan

Student Name:

Gender:

D.O.B.:

Date

Preferred Name:

Preferred Pronouns:

Full Address, including city, state, and zip code:

Email:

example@example.com

Phone #:

Format: (000) 000-0000.

Primary Language:

Emergency Contact:

Relationship:

Emergency Phone #:

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Email:

example@example.com

Race (mark all that apply):

Ethnicity:

Disability Documentation Type:

Disability Diagnosis:

Functional Limitations:

Medications:

Allergies:

School Name:

Grade:

School Contact Name:

Relationship:

Contact Phone #:

Format: (000) 000-0000.

Contact Email:

example@example.com

Service Plan/Service Requested (check all that apply)

I am requesting Transition (Pre-ETS) Services based upon the criteria, I am a student with a disability. I understand I will need to meet with a Transition Services Provider and develop a service plan that will be approved by MassAbility before I start receiving services. I understand, as a recipient of services from MassAbility, I have the right to seek advocacy services from the MassAbility Ombudsman Office at MBY-ombudsperson@mass.gov.

Student Signature:

Date:

Date

Parent/Guardian Signature:

** If student is under 18 or has a legal guardian, their signature is required **

Date:

Date

Please upload your disability documentation (IEP, 504 Plan, Medical Documentation, etc.).

MassAbility Transition Services (Pre-ETS) Potentially Eligible Intake & Service Plan

Participant Information

School Information

Consent for Service

Disability Documentation Upload