Smart Staffing Group, Inc.

82 Washington Street Suite 209

Poughkeepsie, NY 12601

Pre-ETS Youth Referral Form

To be completed by Student/Parent or Guardian


Student Name: ______________________________


DOB: ___________________


Age: __________

*Social Security Number: _______________________________________ Gender:  Male  Female  Prefer not to disclose

__________________ (fill in the blank)


School: _________________________


Grade: ________________________________


Parent/Guardian Name: _____________________


Home and/or Cell #: ____________________________


Address: __________________________________



Email: ____________________________________

Preferred pronouns:

 He/His  She/Her  They/Them

Do you have any food allergies?  Yes  No
Please specify your ethnicity:  White  Hispanic or Latino  Black or African American  Native American or American Indian  Asian / Pacific Islander  Other:  ______________________________
Please select your eligibility.  IEP  504 Plan

 Medical Documentation  Other


Do you have an active case with ACCES-VR?                                                Yes     No



Referral Source: ______________________


Phone: _________________


Referral Date: __________


Referral Agency/School: ____________________________________________________________________

Benefits: The PRE-ETS Program aims to prepare students for life after high school and successful long-term employment consistent with their strengths, abilities, interests, and informed choices. The following topics will be covered:

  1. Job Exploration Counseling
  2. Workplace Readiness Training
  3. Self-Advocacy for Students
  4. Work-based Learning Experience
  5. Counseling on Post-Secondary Opportunities for Students











For Parent/Guardians



I understand that this is not an application for services from ACCES-VR. Pre-ETS Program is committed to good privacy practices. Pre-ETS Program requires access to personal information about you, which will be maintained by Pre-ETS Program.


By signing this form, you are authorizing Pre-ETS Program to access any personal information to determine eligibility to receive Pre-ETS services.


Please note that Pre-ETS Program will continue to protect confidential information maintained about you from release to the public or other unauthorized parties.


I hereby give Smart Staffing Group permission to disclose information relating to my child to the Adult Center and Continuing Education Services-Vocational Rehabilitation (ACCES-VR), including disability information.


*Parent/Guardian Signature: __________________________________                       Date: ______________________


*Student Signature: __________________________________                                     Date: ______________________


Pre-ETS Program Supervisor Signature: _________________________        Date: ______________________
























All potential clients please be aware that our questions on this referral form are designed to serve our clients with the best services available by our agency.


We respect and are sensitive to all race, gender, and cultures in our community.


We as an agency would never practice discrimination or bias on the grounds of race, sex, or cultural differences.