Service Request Form

Service Request Form
Initial request for servicesService ContinuationI am currently a VR client
Student Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name*
School Phone*
Please enter a valid phone number.
Grade*
Expected Graduation Date
If you need accommodations to participate in Services, please describe what you will need here.
Pre-Employment Transition Services Requested
Check All that Apply*

Job Exploration CounselingWorked Based Learning ExperienceWorkplace readiness trainingSelf-Advocacy Instruction/ Peer-MentoringCounseling on Opportunities for Post-Secondary Education/Training
We request this Contractor/Company name for the above service
Complete the Following for Initial Request
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security Number*
Race/Ethnicity (Check all that apply)*

AsianAmerican Indian/Alaskan NativeBlack/African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhite
Are you receiving services from any of the following? (Check all that apply)

Department of Child SafetyBehavioral HealthDivision of Development Disabilities
By signing this form, I am requesting Pre-employment Transition Services from Grad Solutions. I understand that in order to pursue VR services, other than Pre-employment Transition Services, I will need to complete an application and provide VR with information needed to determine my eligibility. For the specific purpose of participation in Pre-Employment Transition Services, I grant permission for my school to release information to VR, and for VR to use personal and demographic information identified in this form to track the services provided to me. The confidentiality of personal information requested on this form and with this authorization is protected by 34 CFR 361.38.*

Clear
Print Signature*

First NameLast Name
Today's Date*

MonthDayYear
Date
*If the participant is under 18, a parent or guardian signature is required. Legal guardianship documents must be provided.*

ParentLegal Guadian
Signature

Clear
Print Signature

First NameLast Name
Student with Disabilities Verification
Definition: A ‘student with a disability’ means an individual with a disability in a secondary, postsecondary, or other recognized education program who is not younger than 14 and not older than 22 years of age; is eligible for, and receiving
special education or related services under Part B of IDEA; or who is a student with a disability under section 504. This includes secondary students who are homeschooled, and students in non-traditional secondary education programs such as special education programs within the juvenile justice system, GED programs, and occupational training programs.
If this request is being completed by school personnel, please verify the following:
By signing this form, I verify that the individual identified above meets the definition of a student with a disability and is

A student with a disability for the purposes of section 504; orA student with a disability and is receiving services under an Individualized Education Plan (IEP)
School Personnel Signature

Clear
Print Signature

First NameLast Name
If this request form is being completed by VR personnel, please verify the following:
By signing this form, I verify that the individual identified above meets the definition of a student with a disability and is:

A student with disability for the purposes of Section 504; orA student with a disability and receiving services under an Individualized Education Plan (IEP); andEligible or potentially eligible for VR services
VR Personnel Signature

Clear
Print Signature

First NameLast Name
If this request form is being completed by non-school/VR personnel, one of the following supporting documents must be included with the submitted request form:

● Individualized Education Plan (IEP) or 504 Plan

● Proof of receipt of SSI/SSDI based on individual’s own disability (SSI/SSDI award letter)

● Medical or psychological documentation with diagnosis signed by a licensed professional
Supporting Document Upload

Cancelof
Contractor Use Only
Contractor Name*

First NameLast Name
Services Requested Check all that apply*

Job Exploration CounselingWork-Based Learning Experience(s)Workplace Readiness TrainingSelf-Advocacy Instruction/Peer MentoringCounseling on Opportunities for Enrollment in Comprehensive Transition/Post-Secondary Education ProgramThe student/family has been provided information on how to pursue vocational rehabilitation service
Provide total number of sessions and dates to complete workshop category type*
Signature of Contractor Representative*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Service Request Form

Pre-Employment Transition Services Requested

Complete the Following for Initial Request

Student with Disabilities Verification

If this request is being completed by school personnel, please verify the following:

If this request form is being completed by VR personnel, please verify the following:

Contractor Use Only