Please note that forms marked with an asterisk (*) are required.
Please let us know which best describes you:
Is the referred person aware of and has consented to this referral?
Before submitting this form the referrer must ensure that the referred person is aware of and has consented to being referred to VisAbility. A referral cannot be submitted or accepted without consent.
Are your contact details the same as the person being referred?
Visual Field (Adult)
Peripheral field remaining in degrees from fixation:
Is the field of vision constricted to 10 degrees or less from fixation? (i.e. less that 20 degrees diameter)
Combination of Visual Acuity and Visual Field Loss (Adult)
If visual acuity is NOT less than 6/60 and field of vision is NOT constricted to less than 10 degrees from fixation:
Does the combined effect of reduced visual acuity and reduced field of vision result in the same degree of impairment as <6/60 or <10 degrees from fixation? (i.e. less than 15% visual efficiency)
Is the level of vision listed above permanent?
Eligibility Criteria (Child)
Please select the relevant statement:
Relevant Medical Conditions
Is the client medically stable?
Degree of Motor Impairment
Degree of Sensory - Perceptual Impairment
Visual processing problems:
Inattention / neglect vision:
Inattention / neglect body:
Degree of Cognitive Impairment
Attention / concentration:
Daily Living Skills