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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 email@example.com. Filling out this form does not guarantee enrollment. This form is HIPPA compliant and encrypted.
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-
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.
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