Make a referral - Guide Dogs NSW/ACT

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Fields marked with * are required.

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.

What's your preferred method of correspondance*

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

Do you have any relevant medical documents to upload?*

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.

I’d like to be added to the monthly Client newsletter mailing list.

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Make a referral.