Project Possibility Referral Form

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For questions please call 212-677-4650 ext. 24 or email projectpossibility@includenyc.org. * = a required field

Your email

Request Info

What do you hope the young person will achieve by participating in Project Possibility?

I am concerned about

Public education systemNon-school systems or concerns

My Specific Areas of Concern are

Diploma Options	Post Secondary Education/ College
Other

My Specific Areas of Concern are

Navigating Systems: OPWDD	SSI/SSDI
Vocational/Employment Training	Other

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Referral Source Information

First name

Last name

Relationship to applicant

School role

Referral Source Organization/ School (if applicable)

Organization/ School Address (if applicable)

Phone

Alt. Phone

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Parent/Guardian Information

First name

Last name

Relationship to applicant

Phone

Email

Primary Language

Parent/Guardian Address

Street

City

State

Zip

Borough

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Education Achieved (Applicant/Youth)

Highest Grade Completed

High School Name

Graduation / Expected Graduation Date

College Name

Semesters Completed

Purpose of Referral

Describe other post secondary goals (if applicable)

First Name	Last Name
Phone Alt. Phone Applicant Address Street City State Zip Borough Primary Language Individualized Education Program (IEP) Classification (if known)	Email Birthdate
Other disability Services received in school (Please select all that apply) Early InterventionGeneral EducationHome InstructionHospital InstructionIntegrated Co-Teaching (ICT)ParaRelated Services CounselingRelated Services Health ServicesRelated Services HearingRelated Services Occupational TherapyRelated Services Physical TherapyRelated Services Speech / LanguageRelated Services VisionSpecial Education Teacher Support Services (SETSS)Special Education ClassOtherUnknown Other services received, if any What educational or vocational activities has the applicant been participating in during the past year?