Youth Low Vision Referral Form

BSBP Logo

 

 

YOUTH LOW VISION

REFERRAL FORM

 

REQUEST FOR YOUTH LOW VISION SERVICES

Eligibility: Youth, age birth through 26 receiving Visually Impaired Services through the local school district may be eligible based upon one of the following criteria:

  • Visual acuity of 20/70 or less in the best corrected eye

  • Visual field restriction less than 20 degrees or less

    _____       Application for service: An eye report must be included with this referral if this is the first time Youth Low Vision Services are being requested on behalf of identified student.

    _____       Referral for Bi-Annual Evaluation

    _____       Other: ______________________________________________________

    Student’s name: _____________________________________________

    (Please Print)

    Date of birth: ________________________________________________

    Address: ___________________________________________________

    City, state, and zip code: ______________________________________

    Telephone number, including area code: _________________________

    Race: ______________________           Gender: ____________________

    Vision/Medical Insurance: _____________________________________

    Low Vision Provider: _________________________________________

    Teacher Consultant: ___________________Telephone:_____________

    School District: ______________________________________________

    Parent/guardian signature

    I am applying for Youth Low Vision services available from the Bureau of Services for Blind Persons (BSBP) on behalf of my child. In signing this referral form, I also authorize BSBP staff to share information with the referring school district and low vision practitioner as necessary to provide optimal services.

     

    Signature: ________________________________ Date: _____________

     

    Print name: _________________________________________________

     

    Contact Number: _____________________________________________

     



Related Documents
Youth Low Vision Referral Form - Word DOC icon