MRC Pre-Employment Transition Services Referral and Consent Form

If you or your student is interested in participating in CLW’s Pre-Employment Transition Services (Pre-ETS) program, please fill out the Referral and Consent Form. If you have any questions on the form or would like a hard copy of this form, please contact Noelle Balutis at nbalutis@centerlw.org. Filling out this form does not guarantee enrollment. This form is HIPPA compliant and encrypted.

I. Demographics

First Name*

Last Name*

SSN

(not required)

D.O.B.*

Primary Language

Race Ethnicity

(mark all that apply)

American Indian or Alaska Native
Asian
Black or African American
White
Hispanic or Latino (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

Disability Documentation Type

IEP
504 Plan
Medical Documentation
Other

Disability Diagnosis

Functional Limitations

Medications

(only fill in if relevant)

Allergies

(only fill in if relevant)

II. Family/Emergency Contact

Name

Relationship

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone Number

Email

III. School Information

School Name

Grade

Expected Exit Date

School Contact Name

Relationship

Contact Phone

Contact Email

IV. Services Requested

(please check off all boxes that apply)

Services

Job Exploration Counseling
Work Readiness Training
Work-based Learning Experience
Instruction in Self-Advocacy/Peer Mentoring
Counseling 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.

Student Name

** if student is under 18 or has a legal guardian, their parent/guardian signature is required**

Signature

Date

Parent/Guardian

Signature

Date

Consent

I agree to the privacy policy.

Signature