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Who is making the referral? *

Referrer Details

First name *

Last name *

Organisation *

Your Position *

School *

Your relationship to person you are referring *

Mobile or Landline * Format: AreaCode + No.

Email *

Client Details

Title

First name *

Last name *

Gender *

Birthdate *

Does the person identify as Aboriginal or Torres Strait Islander?

Is an Interpreter required? *

If Yes, please state the Language

Mobile or Landline * Format: AreaCode + No.

Preferred method of correspondence*

Address

Street

Suburb/Town

State

Postcode

What assistance do you require from Guide Dogs NSW/ACT? * 32768 characters remaining

Please provide information about their vision * 32768 characters remaining

What support can Guide Dogs NSW/ACT offer this student or your school? * 32768 characters remaining

Do you have additional medical information you would like to provide?*

Please provide information about your vision * 32768 characters remaining

Additional Details

Please select to upload relevant documents* Vision ReportDischarge SummaryOther Medical InformationMedical Action Plans

Vision report

Discharge Summary

Medical Action Plans

Other Medical information

Do you receive funding from: *

Does the client receive any funding from any of the following: *

Provider Number

Other – Please specify *

Details of their vision status

Date of diagnosis

Does the person use a mobility aid?*

Please provide details*

Is the vision status related to an Acquired Brain Injury?*

Site of lesion (If applicable):

Cognitive impairment (If applicable):

Is the person currently involved in therapy?*

What therapy is the client currently involved in?*

Communication Preferences

Where did you hear about us? *

I’d like to be added to the mailing list for Guide Dogs' newsletter for professionals.

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