[nfbmi-talk] ingham transition still using peckham mcb mrs

joe harcz Comcast joeharcz at comcast.net
Mon Jun 18 14:56:30 UTC 2012


REFERRAL PROCEDURESIngham Intermediate School District Remember to 
invite the 
LINKS staff 
to this 
student’s IEP The Center for Career Preparation & Assessment 
for 
LINKS and LINKS Alternates 
Students identified as LINKS Program alternates will receive a comprehensive career 
assessment. Upon the event that a LINKS Program slot becomes open, they may have the 
opportunity to enroll in the LINKS Program and participate in additional LINKS Program 
activities. 
ALL REFERRALS SHOULD BE SENT TO: DANIELLE REDMAN – CAREER ASSESSMENT SUPPORT 
INGHAM ISD / CAREER ASSESSMENT SERVICES 
611 HAGADORN ROAD 
MASON, MI 48854 
517-244-1381 
dredman at inghamisd.org 
The following items must be completed with the referral form in order for a career assessment to proceed: (please check that each item is completed and/or attached) ? Referral Form: (required) Please complete the 2011/2012 LINKS referral form with the student as accurately and detailed as possible. 
? Consent and Release of Information Form: (required) 
The Consent and Release of Information Form authorizes Career Assessment Services to release information 
via telephone conversation, fax or written form to the referral source or other designated individuals. 
? Educational Development Plan (EDP) and/or Transcripts: (optional) ? Individualized Education Program (IEP) and/or Transition Plan: (required) 
A copy of the current IEP, including Transition Plan (if applicable) is required, if receiving Special Education 
services. In addition, any background information and social history may be helpful as it allows the 
assessment staff to develop realistic recommendations for the students. An assessment cannot occur 
unless an IEP is included with referral form if student is receiving Special Education services. ? Section 504: (if applicable) ? Call Bus Garage for Student Transportation: (required) Referral source needs to contact bus garage to arrange transportation 
* After the student has completed the comprehensive career assessment the staff from Peckham Inc. will be contacting 
the student to set up appointments for work based learning experiences. In addition, follow-up services may be 
scheduled. *Results will be reviewed with the student at the final appointment. Career Planner Reports will be mailed to the referral 
source, guardian, and Peckham Inc. 
Page 1 of 7 
Ingham Intermediate School DistrictThe Center for Career Preparation & Assessment 
LINKS: Linking Career Assessment and Career Exploration 
to Transition Success 
(A PROGRAM AFFILIATED WITH MI CONNECTIONS) 
Date Rcvd _________ 
Msg Left: _________ 
__________________ 
__________________ 
Date Sched:________ 
SE ________ 
Table with 5 columns and 4 rows2011/2012 LINKS REFERRAL FORM(This form can be duplicated) 1. STUDENT DATA: 
Name: 
Address: 
School: 
Phone #: Birthdate: 
City: 
Grade: 
Expected Graduation Date: Zip: Age: 
Gender: M/F 2. EMERGENCY CONTACT: 
Name: 
Home #: Relationship: 
Work #: 

Table endEmail: 
Table with 3 columns and 4 rows3. REFERRAL SOURCE: 
Name: Title/Position: 
School: Email: 
 Phone #: Best Time to Call: Table end4. WHAT ARE YOUR EXPECTED OUTCOMES FOR THE COMPREHENSIVE ASSESSMENT: ? Career Exploration ? Increased Self Awareness ? Assistance with Transition Planning ? Explanation of Post Secondary 
Educational options ? Learning about appropriate career ? Obtain Capital Area Career Center 
choices (CACC) information ? Understanding training requirements ? Tour of CACC programs 
of various jobs 
? To obtain information for use in a ? Other:___________________________ student’s EDP and/or IEP 
Page 2 of 7 
5. EDUCATIONAL INFORMATION: Please include student’s most recent percentile for reading 
from standardized testing and the most recent level received on the English Language Arts 
MEAP. Reading MEAP (if available) 
6. STUDENT INFORMATION: Check One YEAR IN SCHOOL: Check One RACE / ETHNICITY: 
? Up to 8th Grade ? Freshman ? Sophomore ? Junior ? Senior ? Dropped out of HS ? Certificate of completion-HS ? School Diploma/ GED ? Other: ? White ? Black / African American ? Hispanic ? Asian ? American Indian or Alaskan Native ? Native Hawaiian or Pacific Islander ? Multi or Biracial ? Other: ? Not Reported DISABILITY INFO SECURED FROM: 
? Youth (If youth is checked other documentation must be secured) ? Medical Records ? 504 Plan ? IEP/ITP ? Other: Table with 3 columns and 15 rowsDISABILITY / IMPAIRMENT Primary 
(Check 
One) Additional 
(Check all 
that apply) Specific Learning Disabilities ? ? Attention Deficit 
Hyperactivity Disorder 
(ADHD) ? ? Orthopedic Impairments ? ? Visual Impairments 
(including blindness) ? ? Hearing Impairments 
(including deafness) ? ?Serious Emotional 
Disturbance ? ?Traumatic Brain Injury ? ? Cognitive Impairment /MR ? ? Autism ? ?Speech or Language 
Impairments ? ? Other Health Impairments ? ? Other Psychiatric ? ? Not Reported ? 
Other:__________________________________________ Table endTable with 2 columns and 13 rowsREFERRED TO 
PROGRAM BY: Check 
One Presentation / Meeting ? Brochure ? Parent / Guardian ? School Professional ?  Michigan Rehabilitation 
Services ?  Michigan Commission 
for the Blind ? Michigan Works! ? Center for Independent 
Living ?  Community 
Organization ? Not Reported ? Other:__________________________ 
Table endPage 3 of 7 
Table with 2 columns and 11 rowsPUBLIC ASSISTANCE SERVICES 
RECEIVED: Check all 
that apply SSI Recipient ? SSDI Recipient ? Michigan Rehabilitation Services (MRS) ? Michigan Commission for the Blind (MCB) ? TANF / Welfare Recipient ? WIA / Michigan Works! ? IDEA/ Special Education ? Mental Health Services ? MR / Developmental Disability Services ? Free / Reduced Lunch Program ? Table endTable with 2 columns and 8 rowsCURRENT EMPLOYMENT STATUS: Check all 
that apply Never worked /Enrolled in school 
full time ? Never worked ? Not currently working ? Currently working (Not including 
internships) ? Full – time (35+ hours) ? Hourly Wage ? Not Reported ? Table end7. CURRENT INDIVIDUALIZED EDUCATION PLAN (IEP) INFORMATION: Is this student receiving Special Education services? ____Yes ___ No ___ Former 
Primary Disability: Secondary Disability: 
Please Note: If student is receiving Special Education services an IEP must be received in order for an assessment to 
occur. 
Date last IEP was held: Does this student have a 504 plan: Yes No 
8. POTENTIAL AREAS OF SUPPORT FOR SUCCESS IN EMPLOYMENT AND TRAINING: (please check those that apply) 
? Medication considerations ? Transportation considerations ? Motivation ? Assistance with organization ? Assistance with communication ? Increase work skills ? Assistance with impulse control ? Increase academic skills ? Physical limitations considerations ? Physical stamina considerations ? Reinforcement of appropriate behaviors ? Speech/Language considerations ? Assistance with reading, writing, spelling, ? Assistance with decision making/ problem 
math solving 9. BEHAVIORAL OBSERVATIONS IN THE CLASSROOM: Strengths: 
Challenges: 
Page 4 of 7 
10. MEDICAL INFORMATION 
List medical conditions or characteristics that would affect this student’s ability to 
do certain kinds of testing or work: _________________ ________ 
Medications: Yes __No If yes, please list:
Glasses: Yes ___No When should be worn? 
Hearing Aid: ____Yes ___No
Seizure disorder: (indicate type and frequency): 
Physical restrictions: 
Medical complications: 
11. WORK/SCHOOL INFORMATION: 
Is this student behind in credits or ever been retained? Yes No 
Does the student receive Free / Reduced Lunch Program Yes No 
Has student worked: Part-time? Yes No Full-time? Yes No 
If yes, where? 
Is the student currently employed? Yes No 
If yes, where? 
List all careers(s) this student has expressed interest in: 
List all Capital Area Career Center (CACC) Program(s) this student has 
expressed an interest in: 
If enrolled at the CACC, what program? 
(am/pm) 
12. MODE OF TRANSPORTATION FOR APPOINTMENTS: ? School Bus Referral source needs to contact bus garage to arrange transportation. 
? Own Transportation ? Public Transportation 
Page 5 of 7 
13. SCHEDULING: I would prefer to have pre-assessments sent ahead in order to be scheduled for 
three half days: YES NO 
 If the student has not completed pre-assessments ahead it will take four half days. 
I would prefer to have assessments scheduled in the: AM PM Either 
14. COMMENTS/ADDITIONAL INFORMATION: 15. COMMUNICATIONS: Please inform us who should receive the Career Planner Report 
School Staff: 
Guardian Name: 
Table with 2 columns and 2 rowsGuardian Address: 
Additional Recipients: City/Zip Code: For additional Information please contact: 
Mick LaRue, Career Assessment Coordinator  (517) 244-1328 Table endLindy Daman, Career Preparation Assessment Specialist (517) 244-1370 
and LINKS Specialist 
Cindy Leyrer, Career Assessment Specialist (517) 244-1338 
Danielle Redman, Career Assessment Support (517) 244-1381 
Fax (517) 676-3108 
Page 6 of 7 
Ingham Intermediate School District 
LINKS and LINKS Alternates 
Students identified as LINKS Program alternates will receive a comprehensive career assessment. 
Upon the event that a LINKS Program slot becomes open, they may have the opportunity to enroll in 
the LINKS Program and participate in additional LINKS Program activities. 
 (In Affiliation with MiConnections) 
Consent & Release of Information Form 
? Consent: 
I give my consent for ___________________ to participate in a comprehensive career assessment. This assessment can 
include an evaluation of the student’s current skills, abilities, career interests and other related factors. This information 
is best used to assist the student in identifying future career goals and related educational planning. 
? Release of Information: 
I understand that a Career Planner Report will be sent to the referral source, student parents and/or guardians upon 
completion of the assessment. Federal law requires written parental/guardian consent to release information to agencies 
outside of the school system. This information is necessary in order for your student to participate in the services 
available through the LINKS Program/Ingham Intermediate School District/Peckham, Inc. These services can include 
job shadows, job tours, e-mentoring and/or additional career exploration. 
I, __________________________________, (parent or guardian), authorize the mutual communication/exchange of 
information regarding my student between MiConnections and LINKS Program/Ingham Intermediate School District and 
Peckham, Inc. and Michigan Commission for the Blind and Michigan Rehabilitation Services, if applicable. 
I, _________________________________, (parent or guardian), grant permission for LINKS Program staff and 
Michigan Rehabilitation Services staff to attend my student’s Individual Education Team meetings, if applicable. 
MiConnections and LINKS Program has my permission to photograph/video my student for use in various media. 
____________NO ____________ YES 
MiConnections and LINKS Program has my permission to use my student’s name for use in various media. 
____________NO ____________ YES 
? Permission for Participation: 
I grant permission for my student to participate in job shadows, employer visits and e-mentoring and for Peckham, Inc. 
staff to provide transportation for my student to and from these activities. I understand that I will be notified of the dates 
and destinations prior to these activities and have the option of making the transportation arrangements myself. I also 
grant permission for my student to be released from school to attend these activities with Peckham, Inc staff, as prearranged with school staff. In addition, I understand that Peckham, Inc. will provide liability coverage during the hours 
specified for the job visits. 
Project Excellence of Michigan State University and other research entities working with MiConnections and LINKS Program and its 
service providers to evaluate the project to help MiConnections and LINKS Program meet its reporting requirements and for the 
continuous improvement of the program. To do this, MiConnections, its service providers, Project Excellence and other research 
entities will be collecting information about each participant, their program related activities and their satisfaction with the program. 
Any information collected by MiConnections, its service providers, Project Excellence and other research entities will be kept 
confidential and only group data will be reported in any reports or publications related to the project. 
MiConnections, MiConnections service providers, Project excellence and other research entities have my permission to collect and report 
the information as described above. This agreement for consent and release will expire upon the student’s graduation from high school. 
Guardian Signature: ________________________________ Date: ________________ 
or Student with Adult Status 
Page 7 of 7 



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