Disability EmpowHer Network PE Referral Fillable Form

Request for Pre-Employment Transition Services for Potentially Eligible Students with Disabilities

Referring Potentially Eligible Provider: Disability EmpowHer Network
Disability EmpowHer Network provides Pre-Employment Transition Services (Pre-ETS), as defined by the Workforce Innovation and Opportunity Act (WIOA), to a student(s) with a disability who is eligible or potentially eligible for VR services.

A student with a disability is defined as an individual who is enrolled in an educational program, is between the ages of 14 and not yet 23 and is eligible for special education and related services under IDEA or is an individual with a disability for Section 504 of the Rehab Act.

In collaboration with schools and other community partners, pre-ETS will be made available to students with disabilities who require one or more of these services.

The following information, completed by students along with school, families or community providers, should be sent along with documentation of the student's disability for any potentially eligible student who is not currently receiving VR services. In completing this form, please do what you can as you are able. The most important information needed to start a referral will be the Student Background Information. If you need support completing the rest of the form or have any questions, just ask!
Section 1: Student Background Information (all fields required)
Name Last
Name First
MI
Suffix
Social Security Number
Birth Date (mm/dd/yy)

MonthDayYear
Date
What would you like us to call you?
What is your gender identity?

WomanManNon-binary/gender-nonconformingChoose not to discloseOther
What are your pronouns?

She/herThey/themHe/himOther
County of Residence
Address

Home Address Street

Street Address Line 2

CityState

Zip Code
Phone Number (10-digit)
Phone Type

VoiceTTYVideo Phone
Email Address
example@example.com
Race/ethnicity

American Indian or Alaskan NativeAsian/Pacific IslanderBlack or African AmericanHispanicWhite/CaucasianOther
Are you Hispanic or Latino?

YesNo
U.S. Citizen? If no, please select 'Other' and specify your immigration status.

YesOther
What is your primary disability?
Need for auxiliary services?

ReaderInterpreterOther
Other disability-related information
Section II: Request for Pre-Employment Transition Services, to be completed by the student or their referral source (all fields required)
Below are the Pre-Employment Transition Services offered. These services are intended to be the earliest set of services to assist students with identifying career interests and to provide the ability to practice and improve workplace skills. You may elect to receive some or all of the services.
Please check which services you are interested in receiving:

Post-Secondary Options CounselingJob Exploration CounselingInstruction in Self-AdvocacyWorkplace Readiness Training to Develop Social Skills and Independent Living
Which documentation of disability are you providing us?

IEP504 PlanSSA Award LetterOther diagnostic documentation
Specify:
Are you currently in high school?

YesNo
Are you currently enrolled in a post-secondary program?

YesNo
If yes, what grade are you in?
Expected Graduation/Exit Date

MonthDayYear
Date
Referring organization (School, college, agency, or other)
Referral Source
Referral Source E-Mail
example@example.com
Referral Source Relationship
Phone Number (10-digit)
Address (Street, City, State, Zip)
READ BEFORE SIGNING:

I understand this is not an application for services from Adult Career and Continuing Education Services - Vocational Rehabilitation (ACCES-VR) or for the Commission for the Blind.

Disability EmpowHer Network is committed to good privacy practices. As such, Disability EmpowHer Network is disclosing that to fully process your request for Pre-Employment Transition Services, access is required to personal information about you, which will be maintained by the Potentially Eligible provider. By signing this form, you are permitting access to any personal information (PII) necessary to process your request for Pre-Employment Transition Services, to provide these services to you. Please note that Disability EmpowHer Network protects any non-public, confidential personal information maintained about you from release to the public or unauthorized third party. By signing below, I authorize ACCES-VR to obtain/release information (including school records, disability information and status of ACCES-VR process By signing below, I acknowledge that in completing the request for Pre-Employment Transition Services, Disability EmpowHer Network may obtain or release confidential personal information about me as follows: in collaboration with ACCES-VR vendors and Partners on my behalf to report my progress to the school or agency who referred me to Disability EmpowHer Network when required by law and to facilitate the administration of the Rehabilitation Act to other state agencies, if applicable Disability EmpowHer Network does not discriminate against any applicant for services on the basis of race, color, religion, national origin/ancestry, disability, age, sexual orientation, gender, veteran or military status, and/or genetic information or in any manner prohibited by law.
Signature of the individual (If under 18, the parent or legal guardian must also sign below)

Clear
Date

MonthDayYear
Signature of Parent or Legal Guardian if applicable

Clear
Date

MonthDayYear
Date
Parent or Legal Guardian Name, if applicable
Parent or Legal Guardian E-Mail
example@example.com
Parent or Legal Guardian Phone Number
Should be Empty:

Request for Pre-Employment Transition Services for Potentially Eligible Students with Disabilities

Section 1: Student Background Information (all fields required)

Section II: Request for Pre-Employment Transition Services, to be completed by the student or their referral source (all fields required)