Title: Send or email Completed form to:
Author: Peter Lafferty
Last saved by: Kathleen Kenney
Company: DMR

(Office Use)
Date Received:

Referred To:

Please email completed form to:
Teryl.Smith@mass.gov
Please cc: DDS Area Director and 
Lisa.DiBonaventura@mass.gov 
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:
Area Office: | Email:

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 Name:      
Address:      
Phone #:                                             
☐ Ophthalmologist            ☐ Optometrist 

Date of most recent eye exam:

Primary Care Provider Name:      
Address:      
Phone #:

Should DDS Service coordinator be contacted prior to first visit?   ☐ Yes     ☐ No

Others To Be Contacted (if applicable)

Parent/Guardian:

Email: 
Phone:

Occupational Therapist:

Email: 
Phone:

Physical 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?