(Office Use)
Approved:
Denied:                   Reason:

Referred To: 	

E-mail Completed form to:
Peter Lafferty
Wrentham Developmental Center
P.O. Box 144
Wrentham, MA 02093 	

Wrentham Developmental Center
Request for Services

Name:      	
Date of Referral:      	
Address: 

	     

	Telephone:      

Contact Person:      	
Service Coordinator:      	Telephone:      	
Area Office:      		
Day Program:      
Address:      
Type:   Vocational   Day Habilitation  Supported Employment
              Other: 
Contact Person:                                 Phone #:      	
Type of Service Requested:
  O &M / Low Vision Assessment  PT Eval.   OT Eval.
  Adaptive Design (ATRC)  APE Eval (Please include current, completed Medical Clearance & the Health Review for Participation in an Exercise Program forms. Forms must be dated within 45 days of this request).

 Lens Crafter Charitable Program (see page 2)   Other:       

* If requesting a low vision or an orientation & mobility assessment, please mail copies or fax copies of the most recent eye reports to Lisa DiBonaventura, P.O. Box 144, Wrentham, MA 02093 or fax to (508) 384-5612.	
Reason for Referral:      	
Identifying Data: 	
Date of Birth:      
	Language Spoken:      	
Diagnosis:      	Functioning Level:      	
Psychiatric Diagnosis:      
	Other:      	
What Community Resources Have Been Explored? (please include date of contacts and why service was not provided):       

	
Please Complete the following sections if applicable:	
Medical  / Health Issues:      

Mental Health Issues:      

Behavioral Issues:      
	
Other:      	
O&M Referrals: Eye Doctor Information
Name:      
Address:      
Phone #:                                               Optometrist            Ophthalmologist	
Lens Crafter Gift of Sight Charitable Program Request

Contact Person:                             Telephone #:     
Mailing Address:      

Mailing Address of Lens Crafter Store:      

Store Phone #:      

Date of Prescription:      
Please Describe other Sources of Payment That Have Been Explored: