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:
Lisa.DiBonaventura@mass.gov
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: 
Primary Language:

Contact Person/Role: 
Phone #:                                                  Email:      
Language Spoken:

Date of Birth: | Guardian  ☐Y  ☐ N (List name on page 3.)

DDS Service Coordinator:

Telephone: 

Email:

Area Office: |

Day Services/Employment:      

Address:      

Type:  ☐ Vocational  ☐ Day Habilitation ☐ CBDS/ Community   ☐  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                               
☐ Other:

Reason for Referral/ Desired Outcome:
Mental Health/ Behavioral Concerns:
Medications:
Medical Health Issues:

Eye Care Provider Name:
Address:
Phone #:
Date of most recent eye exam:
Cause of Legal Blindness:

Primary Care Name: 
Address:
Phone#:

Guardian Name: 
Address:
Phone#:
Email:
Should Guardian be contacted?  ☐ Yes    ☐ No

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

Occupational Therapist:

Email: 
Phone:

Physical Therapist:

Email: 
Phone:

Speech Pathologist:

Email: 
Phone:

Other Specialist:

Email: 
Phone:

Any other concerns/questions you would like to have addressed with Orientation and Mobility Services?

*Please attach a copy of the most recent ISP, the Health Record, and ANY Behavioral Guidelines or Leveled Plans.