Referral Form- Assistive Technology Independent Living Program
Select the ESMA Program from the list
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Assistive Technology Independent Living Program
Name
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First Name
Last Name
DOB
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Month
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Day
Year
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Primary Language
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone
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Home Phone
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Please select your closest gender from the list
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Male
Female
Transgender
Gender Nonconforming
Non binary
Gender queer
Gender fluid
Other
Multiple
Please select your living situation from the list
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Apartment
Home
Group Home
Please select your education level from the list
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Associates Degree or Higher
Masters degree or higher
Bachelors degree or higher
Elementary School
High School diploma/GED
Middle School
No formal education
Not of school age
Other credentials (degree, certificate)
Some College
Some High School
Some Schooling no High School
Unknown
Do you live with others?
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Yes
No
Please select the closest approximation to race from the list
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American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Some Other Race
Declined to Answer
Please select veteran status from the list
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Active Duty
National Guard
Veteran
Veteran Family Member
No Affiliation
MRCIS # (only relevant if you are an existing MassAbility client))
Please select from the list who referred you to us?
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MRC
DDS
Community Organization
Self
School
Family
Referral Person Name/Title
Referral Email
example@example.com
Referral Phone
Please enter a valid phone number.
Location of Provider Office
Describe relevant medical history
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Describe how medical conditions impact functioning?
0/5000
Describe goals for participating in the program.
0/5000
Who should be contacted for scheduling if other than self?
What is this person's phone number?
Is there anyone else you would like involved in the evaluation?
PCA
Case Manager
Friend
Family Member
Other
What is the person's name?
What is their phone number?
Are you receiving services from any other state agency?
Mass Rehabilitation Commission /MassAbility
Mass Commission for the Blind
Supported Living
Statewide Head Injury Program
Dept. of Developmental Services
Mass Commission for the Deaf and Hard of Hearing
Attach any relevant documentation/authorization
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