• 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 Courtney Cormier, Pre-ETS Skills Trainer at ccormier@centerlw.org. Filling out this form does not guarantee enrollment. This form is HIPPA compliant and encrypted.

  • I. Demographics

  • (not required)
  • (mark all that apply)
  • (only fill in if relevant)
  • (only fill in if relevant)
  • II. Family/Emergency Contact

  • III. School Information

  • IV. Services Requested

    (please check off all boxes that apply)
  • 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.

  • Date Format: MM slash DD slash YYYY