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Rehabilitation Services for the Blind Referral

Rehabilitation Services for the Blind (RSB) offers services to help blind or visually impaired persons reach personal and employment success. If you, or someone you know, would like to talk to a team member about our services, please complete the form below. The information you provide will be sent to our team for review and we will be in contact as soon as possible to discuss services. 

 

Information for person you are referring

Submission ID:

First Name (required)

Last Name (required)

When entering SSN enter numbers only i.e.; 999999999

SSN

Date of Birth (required)

Gender (required)

Male

Female

Does not wish to Identify.

Street Address (required)

City (required)

State (required)

Zip Code (required)

County (required)

When entering phone number enter numbers only i.e.; 9999999999

Phone Number (required)

Email

Is the individual employed? (required)

Yes

No

Would the individual like a job?

Yes

No

The individual is interested in the below services (check all that apply)    (required)

Treatment services for eye condition

Training in daily living skills

Training in mobility skills

Employment services

Assistive technology devices and/or training

Name, phone number and relationship of individual completing referral page

Referral Name

Referral Phone Number

Relationship Referral

How did you hear about RSB? (select one)    (required)

Eye doctor/other medical provider School District Family and friends Welfare agency (state or local government) Other (type in source)

Other Referral Source (required if Other (type in source) is selected above)

If you would like to attach any supporting documentation such as the individual’s eye exams, individualized education plan, Social Security award letters, etc. to help us determine eligibility, please attach them here.

File Attachment

Attach

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Submit

 

 

 

 

 

Thank You

This message confirms that you have submitted a Rehabilitation Services for the Blind (RSB) referral.

Your referral ID is {formuniqueid}.
.

Please keep this number in case you need it. A member of our team will be in contact with the referred person as soon as possible. If you need help now, you can call us at 1-800-592-6004 or send us an email at askrsb@dss.mo.gov.

Thank you,

Missouri Department of Social Services

Rehabilitation Services for the Blind

 

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