RochesterIndependentSchool District #535

Transition to Adult Program
Referral Form

DATE OF REFERRAL:

STUDENT INFORMATION

Student Name ▲ / Date of Birth ▲
Student Address ▲ / Student ID # ▲
Disability area ▲
Parent/Guardian Name ▲ / Home Phone # ▲
Parent/Guardian Address ▲ /
Work Phone # ▲
Email (If applicable) ▲

School and Community Information

Referring School ▲ / Phone # ▲
IEP Case Manager ▲ / Phone # ▲
iep related services (speech, pt, ot, etc) ▲
County Case Manager ▲ / Phone # ▲
Rehabilitation Services Counselor ▲ /
Phone # ▲
Residential/In-House Support Staff (if applicable) ▲
/ Phone # ▲
LEGAL Guardian(S) ▲
/ Phone # ▲

INFORMATION REQUIRED FOR REFERRAL

(Please attach to referral form)

1. Individual Educational Plan (IEP)
2. Current Evaluation Report
3. Medical Information (if appropriate)
  • Include Emergency Health Care Plan

4. Residential Program Plan (if appropriate)
5. Vocational Experience Reports/Evaluations

Community Agencies/Support Systems

These are agencies utilized by individuals with disabilities in their adult life. What is the student’s current status with these agencies/support systems? Please check the appropriate column.

TAP Application 11/3/2018

Completed / Already in progress / Not in Progress / Not Applicable
1 / CountySocial Worker
2 / Residential Services/Support
3 / SEMCIL
4 / ZIPS
5 / City Bus
6 / GovernmentCenter (ID cards, police office, transportation office, etc.)
7 / Social Security
8 / Counseling Services
9 / Personal Physician
10 / Dentist
11 / Pharmacy
12 / Salvation Army (Health Clinic, Social Workers on staff)
13 / Public Health/Nutrition Specialist
14 / Channel One/Food Shelf
15 / Food Stamps
16 / Banking Services
17 / Low Income Housing
18 / Library (videos, Internet)
19 / Community Education
20 / Volunteer Experiences
21 / Park and Recreation Department
22 / Rochester Family Y / Rec.Center
Rochester Athletic Club (RAC/Other)
23 / Hobbies/Sport Clubs
24 / RADAR
25 / Rehabilitation Services (Services for Blind, Deaf, or TBI)
26 / WorkForceCenter (Job Service, PIC)
27 / Ability Building Center/PossAbilities
28 / Assistive Technology (PACTT, CourageCenter, etc.)
29 / RCTC — Support Services Coordinator
30 / Employment Agencies

Student Name Date

School

Completed by

Independently

With reading assistance by

Student Questionnaire

What do you want to learn and accomplish through your involvement

with the Transition to Adult Program (TAP)?

DAILY LIVING SKILLS

  1. Which of the following can you do independently?
    _____ household management_____ minor home repair
    _____ schedule appointments_____ plan meals
    _____ select & care for clothing_____ prepare foods
    _____ budget money_____ use telephone
    _____ time/money/calendar skills_____ use medication
    _____ dressing grooming_____ personal hygiene
    _____ personal fitness (exercise weight control)
  1. Do you do things with friends outside of school?_____ Yes_____ No

If yes, what activities and how often? ______

______

POST-SCHOOL ADULT LIVING

  1. Where do you think you will be living after you leave high school?
    _____ by yourself_____ with a friend/roommate
    _____ with your family_____ group home

_____ with guardian

  1. Who is your guardian? Will this change when you turn 18?

______

______

  1. What is your disability? How does this disability affect your life?

______

______

  1. Do you feel that you should receive information about services available from community agencies?
    _____ Yes_____ No
  1. Do you think you have personal adjustment problems and need advice in any of the following areas?
    _____ acceptance of disabilities_____ acceptance of abilities
    _____ daily coping skills
  1. Do you need information or referrals regarding any of the following?
    Medical ServicesFinancial Services
    _____ doctor/medical clinic _____ supplemental security income
    _____ medical insurance _____ general public assistance
    _____ equipment purchase/maintenance _____ food stamps
    _____ dentist _____ medicaid/medicare

COMMUNITY INVOLVEMENT/SERVICES

  1. Check the following consumer services you can use independently.
    _____ grocery store_____ department/retail store
    _____ beauty salon/barber shop_____ restaurant
    _____ bank_____ post office
    _____ laundromat_____ library
  1. Do you have:
    _____State of Minnesota ID
    _____ Selective Service Registration (age 18)
    _____ Minnesota Driver’s License
    _____ Social Security Number

_____County Case Manager

  1. What types of transportation can you use?
    _____ have own car_____ use of family car
    _____ parents/guardian drives_____ public transportation
    _____ pay others for transportation_____ car pool
  1. What are three things you enjoy doing?

______

______

______

  1. Do you participate in any of the following activities?

_____ community education_____ school clubs/activities
_____ individual hobbies and activities_____ recreation centers
_____ community festivities_____ reading
_____ religious affiliation activities_____ scouting

  1. Do you participate in physical fitness activities?
    _____ individual sports_____ health clubs
    _____ team sports_____ YMCA/YWCA
    _____ other

EMPLOYABILITY/PRODUCTIVE USE OF TIME

1.What job would you like to have when you finish high school? ______

2. List all work experiences you have had (in-school/volunteer/paid): ______

______

______

______

3. Can you work independently when given a job to perform? ______

4.Do you need supervision and support to complete a job? ______

5.Are you interested in continuing school after you leave high school?
_____ four year college/university
_____ two year community college
_____ career center for vocational training
_____ state technical institute and rehabilitation center
_____ adult and community education
_____ military service
_____ other ______

6. Check the words that describe you best.

_____ a leader_____ friendly_____ intelligent_____ prompt
_____ a team player_____ good looking_____ lazy_____ quiet
_____ artistic_____ happy_____ loud_____ sarcastic
_____ careful_____ hard working_____ mechanical_____ serious
_____ competitive_____ healthy_____ organized_____ shy
_____ cooperative_____ helpful_____ patient_____ strong
_____ creative_____ honest_____ persistent_____ sympathetic
_____ daring_____ imaginative_____ persuasive_____ talkative
_____ energetic_____ in a hurry_____ pleasant_____ tired
_____ enthusiastic_____ independent_____ pretty_____ worried

Any Additional Information?:

______

Student SignatureDate

______

Parent/Guardian SignatureDate

______

IEP Case Manager SignatureDate

Send completed form to your SSS Supervisor at ESC

TAP Application 11/3/2018