Program & Services Referral Information Form
Please complete this form to assist us in learning more about the individual needing potential services. Completion of this form does not obligate you in any way to accept our services. By filling out this form, you will receive a follow-up call from Opportunity Matters' administrative staff to provide you with more information about our programs and services and to determine if we can meet your needs.
Indicate which of OMI's services you may be interested in for this individual.
Adult Day Services
Behavioral Consulting Services
Supported Apartment Servics
Individual's PMI #
Sex of Individual
Individual's Medicare #
Type of Waiver/Other
Case Manager's Name
Case Manager Email Address
Legal Representative's Name
Legal Representative Email Address
Contact Person Email Address
(For those interested in Behavioral Consulting, if applicable)
Day Program/School Name
Contact Person's Email Address
Primary Correspondent/Family Contact
Primary Correspondant/Family Contact's Name
Primary Correspondent/Family Contact's Email Address
Was this individual referred by a Physician?
Presenting Problem & Challenging Behaviors (Behavioral Consulting services only)
Person making this referral