MassAbility Pre-Employment Transition Services Referral and Consent Form

I. Participant Information

First Name*

Last Name*

D.O.B.*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Emergency Contact*

Emergency Contact Phone*

Emergency Contact Email*

Primary Language*

Race*

(mark all that apply)

American Indian or Alaska Native
Asian
Black or African American
White

Ethnicity*

(mark all that apply)

Hispanic or Latina (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)

Disability Documentation Type*

Self-attestation of disability (signed by student/guardian)
IEP
504 Plan
Medical Documentation
Other

Disability Diagnosis*

Functional Limitations*

Medications

(only fill in if relevant)

Allergies

(only fill in if relevant)

II. School Information

School Name*

Grade*

School Contact Name*

Relationship*

School Contact Phone*

School Contact Email*

III. 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
Career Camps
Single Service
Virtual
In-Person

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 MassAbility before I start receiving services. I understand that, 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

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 MassAbility 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*