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Who is making the referral? * —Please choose an option—SelfParent/Guardian/Family Member/CarerHealth Professional/Service ProviderGD ProfessionalEducation Professional
First name *
Last name *
Organisation *
Your Position *
School *
Your relationship to person you are referring *
Mobile or Landline * Format: AreaCode + No.
Email *
Do you have consent to make this referral? * —Please choose an option—YesNo
Title —Please choose an option—MrMsMrsMissDr
Gender *
Birthdate *
Does the person identify as Aboriginal or Torres Strait Islander? —Please choose an option—YesNo
Is an Interpreter required? * —Please choose an option—YesNo
If Yes, please state the Language
Email
Preferred method of correspondence* —Please choose an option—EmailPhone
Street
Suburb/Town
State —Please choose an option—Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia
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 choose an option—YesNo
Please provide information about your vision * 32768 characters remaining
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: * —Please choose an option—NDISMy Aged CareVeterans AffairsJob AccessiCareOtherNot Applicable
Does the client receive any funding from any of the following: * —Please choose an option—NDISMy Aged CareVeterans AffairsJob AccessiCareOtherNot Applicable
Provider Number
Other – Please specify *
Date of diagnosis
Does the person use a mobility aid?* —Please choose an option—YesNo
Please provide details*
Is the vision status related to an Acquired Brain Injury?* —Please choose an option—YesNo
Site of lesion (If applicable):
Cognitive impairment (If applicable):
Is the person currently involved in therapy?* —Please choose an option—YesNo
What therapy is the client currently involved in?*
Where did you hear about us? * —Please choose an option—CatchUpConnected Together Peer GroupsExisting CustomerFriends/Family/ColleagueGuide Dogs WebsiteHealthcare ProfessionalInternet SearchMarketing EventNewspaper/Print MediaOtherProfessional Development EventProfessional PublicationRadioReferral – GPReferral – My Aged CareReferral – NDIAReferral – OtherSocial Media
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