MassAbility Pre-Employment Transition Services Referral and Consent Form

MassAbility Pre-Employment Transition Services Referral and Consent Form
I. Demographics
Student Name:*
SSN (if required):
Primary Language:*
D.O.B.:*

MonthDayYear
Date
Gender:*

MaleFemalePrefer not to answer
Race (mark all that apply):*

American Indian or Alaska NativeAsianBlack or African AmericanWhite
Ethnicity:

Hispanic or Latino Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
Address:*
City:*
State:*
Zip code:*
Phone:*
Email:*
example@example.com
Disability Documentation Type:*

IEP504 PlanMedical DocumentationOther
Disability Diagnosis: *
Functional Limitations:
Medications:
Allergies:
II. Family/Emergency Contact
Name:*
Mailing Address:*
Relationship:*
Phone Number:*
Email:*
example@example.com
III. School Information
School Name:*
Grade: *
Expected Exit Date:

MonthDayYear
Date
School Contact Name:
Contact Phone
Relationship:
Contact Email:
example@example.com
IV. Services Requested
Job Exploration CounselingWork Readiness TrainingWork-based Learning ExperienceInstruction in Self-Advocacy/Peer MentoringCounseling for Enrollment in Post-secondary Education Program
V. Consent for Service
I am requesting Pre-Employment Transition Services based upon the criteria that I am a student with a disability. I understand I will need to meet with a Pre-ETS Provider and develop a service plan that will be approved by MRC before I start receiving services. I understand that, as a recipient of services from MRC, I have the right to seek advocacy services from the Client Assistance Program (CAP) at 1-800-478-1234 or http://www.dlc ma.org/.

For the specific purpose of participation in Pre-Employment Transition Services, I grant permission for the service provider to exchange information with the schools, authorized personnel, and MRC to verify services were provided to me.
Signature:*

Clear
Date: *

MonthDayYear
Date
Parent/Guardian Name - Print:
** If student is under 18 or has a legal guardian, their signature is required **
Parent/Guardian Signature:

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

MonthDayYear
Date
Disability Documentation Upload
Please upload your disability documentation (IEP, 504 Plan, Medical Documentation, etc.).

Cancelof
Should be Empty:

MassAbility Pre-Employment Transition Services Referral and Consent Form

I. Demographics

II. Family/Emergency Contact

III. School Information

IV. Services Requested

V. Consent for Service

Disability Documentation Upload