Patient/Student Referral Form

Please complete this form if your student or patient may benefit from the services of Beyond Blindness. Important Warning: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly Prohibited. If you have received this message by error, please notify the sender immediately to arrange for return or destruction. Unauthorized re- disclosure for failure to maintain confidentiality could subject you to penalties described in federal and state law.

Patient Name

First Last

Date of Birth

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Caregiver Name

Primary Language Spoken at Home

Caregiver Phone Number

Caregiver Email

Child's Sex

Check if OK to directly contact caregiver

Yes

Referrer Information

Referring Agency/Office

Phone

Name of person completing form

First Last

Diagnosis/Reason for Referral

Additional Information (optional)

Please check the box for the service(s) you would like Beyond Blindness to explore with the referral. For more information on these programs, please call Beyond Blindness or visit out website at www.beyondblindness.org

Functional Vision or Developmental Assessment

Early Intervention Services/IFSP Services

School Age (3-22) Services/IEP Services

Assistive Technology

Counseling/Mental Health Services

Parent Education/Training/Resource Center

Other

(please specify)