(Office Use)
Date Received:

Referred To: 	

Please 
E-mail Completed form to:
Awilda.Ayala@MassMail.State.MA.US
Please Cc:
DDS Area Director

Thank you! 	

Orientation & Mobility/Low Vision Services
Request for Services

Name:      	
Date of Referral:      	
Home Address:      

     
Type:   Group Home   Shared Living  Lives Alone  Lives with Parents/Family
              Other: 

Contact Person:                                 Phone #:      
Email:      		
Date of Birth:      		
DDS Service Coordinator:      	Telephone: 
Email:     	
Area Office:      		
Day Services/Employment:      
Address:      
Type:   Vocational   Day Habilitation  Supported Employment
              Other: 
Contact Person:                                 Phone #:      
Email:      	
Service Requested:

Orientation and Mobility Assessment     
Environmental Assessment                       
Residential Staff Training                           
Day/Work Staff Training                            
Direct Certified Orientation and Mobility Specialist Services                               
Direct Vision Rehabilitation Assistant Services                                  

 Other:       

Reason for Referral:      	
Language Spoken:	
Medical Health Issues:      	
Mental Health Issues:      

	
Medications:

	
Behavioral Issues:         

 
	
Eye Care Provider Information:                              Date of most recent eye exam:      

Name:      
Address:      
Phone #:                                             

Please check:
  Ophthalmologist             Optometrist      	
Primary Care Provider Information:

Name:      
Address:      
Phone #:                                             
	
Should DDS Service coordinator be contacted prior to first visit?      

Others to be contacted/applicable:     
Parent/Guardian:      	Email:                                         Phone:      
Physical Therapist:      	Email:                                         Phone:      
Occupational therapist:      	Email:                                         Phone:      
Speech Pathologist:      	Email:                                         Phone:      
Other Specialist:      	Email:                                         Phone:      
	
Please give a description of what goals you have for individual receiving this service:	
Any other concerns/questions you would like to have addressed with Orientation and Mobility Services?