Make a Referral for Low Vision Services

Please note that forms marked with an asterisk (*) are required.

Please let us know which best describes you:*

An individual, carer or parent

An Allied Health Professional

Support Coordinator/HCP Provider

A vision specialist, Ophthalmologist or Orthoptist

Any specialist: Acquired Brain Injury (ABI) referral

Is the person being referred aware of and has consented to this referral?*

Yes

No

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.

Client details

First name:*

Surname:*

Address:*

Address:

Address line 1

Address line 2

Suburb / Town

State

Postcode

Email:

Telephone:*

Alternative telephone (optional):

Gender:

Male

Female

OtherOther

Date of birth: (day/month/year)*

Age:

This will be automatically calculated.

Australian residency status*

Permanent

Temporary

OtherOther

Is an interpreter needed to communicate with the client?*

Yes

No

If yes, please state which language:

Current school:

Date of certificate: (day/month/year)

Date of assessment: (day/month/year)

Parent name/s:

Funding sources for referral (if applicable)

National Disability Insurance Scheme (NDIS)

Department of Veterans Affairs (DVA)

Insurance claim

My Aged Care

Self-funded

Other (please provide details)Other (please provide details)

Please provide funding details e.g. relevant registration numbers, contact details etc.:

Please attached any related documents to this referral (max 10mb per file):

Maximum file size: 10MB

Next of Kin

Next of kin first name:

Next of kin surname:

Next of kin email:

Next of kin telephone:

Emergency contact

Emergency contact first name:

Emergency contact surname:

Emergency contact email:

Emergency contact telephone:

Diagnosis (Adult)

Age-related Macular Degeneration (wet/scar)

RE

LE

Date of diagnosis

Age-related Macular Degeneration (dry/atrophy)

RE

LE

Date of diagnosis

Diabetic Retinopathy

RE

LE

Date of diagnosis

Retinitis Pigmentosa

RE

LE

Date of diagnosis

Glaucoma

RE

LE

Date of diagnosis

Cataract

RE

LE

Date of diagnosis

Other

RE

LE

Date of diagnosis

Diagnosis (Child)

Albinism

RE

LE

Both

Cerebral Vision Impairment

RE

LE

Both

Nystagmus

RE

LE

Both

Optic Nerve Hypoplasia

RE

LE

Both

Retinal Dystrophy (state type)

RE

LE

Both

Other diagnosis

Other

RE

LE

Both

Add additional diagnosis Remove diagnosis

Additional information:

Visual acuity (Adult)

Best corrected distance visual acuity:

RE

LE

Both

Is the corrected visual acuity less than 6/60 in each eye?

Yes

No

Visual field (Adult)

Peripheral field remaining in degrees from fixation:

RE

degrees

LE

degrees

Describe the visual field loss:

Is the field of vision constricted to 10 degrees or less from fixation? (ie. less that 20 degrees diameter)

Yes

No

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)

Yes

No

Is the level of vision listed above permanent?

Yes

No

Test results (Child)

Best corrected distance visual acuity:

RE

LE

Both

Please indicate if visual acuity was measured with:

Cardiff Card

Teller Acuity Card

OtherOther

Peripheral field remaining in degrees from fixation:

RE

degrees

LE

degrees

Both

degrees

Describe visual field loss:

Please attach copy of field / electrophysiology test:

Maximum file size: 3MB

Eligibility criteria (Child)

Please select the relevant statement:

Best corrected visual acuity of 6/18 or less (with both eyes open)

Visual field constricted to 30 degrees or less from the point of fixation (or 60 degrees or less in diameter)

Combination of reduced visual field and visual acuity

Cerebral Vision Impairment

Does not meet the above criteria, however has a diagnosis that may indicate a significant reduction in visual function. Please refer if unsure.

Additional information (Child)

Other medical conditions:

Other medical specialists or agencies involved:

Relevant medical conditions

Please list any relevant medical conditions:

Nature of acquired brain injury

Site of lesion:

Date of incident: (day/month/year)

Vision status:

Has the client been assessed by an ophthalmologist or optometrist?

Yes

No

If yes, please attach the report:

Maximum file size: 3MB

Please state the name of the specialist:

If the client has had a neuropsychology assessment, please attach a copy:

Maximum file size: 3MB

Medical history

Contra-indications for program:

General Practitioner's name:

General Practitioner's address:

GP Address line 1

GP Address line 2

GP Suburb / Town

GP State

GP Postcode

General Practitioner's telephone:

Medical status

Is the client medically stable?

Yes

No

Degree of motor impairment

Balance:

Nil

Mild

Severe

Stamina:

Nil

Mild

Severe

Gait (aids):

Nil

Mild

Severe

Comments:

Degree of sensory - perceptual impairment

Vision loss:

Nil

Mild

Severe

Other sensory loss:

Nil

Mild

Severe

Visual processing problems:

Nil

Mild

Severe

Inattention / neglect vision:

Nil

Mild

Severe

Inattention / neglect body:

Nil

Mild

Severe

Spatial orientation:

Nil

Mild

Severe

Ability to read:

Nil

Mild

Severe

Comments

Degree of cognitive impairment

Language receptive:

Nil

Mild

Severe

Language expressive:

Nil

Mild

Severe

Problem solving:

Nil

Mild

Severe

Planning:

Nil

Mild

Severe

Initiation:

Nil

Mild

Severe

Attention / concentration:

Nil

Mild

Severe

Memory:

Nil

Mild

Severe

Insight:

Nil

Mild

Severe

Self-monitoring:

Nil

Mild

Severe

Impulsivity:

Nil

Mild

Severe

Comments:

Daily living skills

Showering:

Independent

Verbal assistance

Physical assistance

Total assistance

Toileting:

Independent

Verbal assistance

Physical assistance

Total assistance

Dressing:

Independent

Verbal assistance

Physical assistance

Total assistance

Eating:

Independent

Verbal assistance

Physical assistance

Total assistance

Cooking:

Independent

Verbal assistance

Physical assistance

Total assistance

Making hot drinks:

Independent

Verbal assistance

Physical assistance

Total assistance

Cleaning:

Independent

Verbal assistance

Physical assistance

Total assistance

Comments:

Rehabilitation Status

What is the rehabilitation status of the client:

In-patient

Out-patient

Please state approximate discharge date: (day/month/year)

What therapies (in or out-patient) is the client involved in?:

What days and times is the client involved in therapy?

Is the client's rehab funded by a specific department? Please select:

ICWA

Veterans' Affairs

Workcover

Not applicable

Please provide claim / pension number:

Case Manager's name:

Where is the client mobilising independently on foot?

Rehab centre

Home local area

Shops public

Transport

What independent mobility and vision goals does the client have?

What is the client's driver's licence status?

Current

Suspended

Cancelled

Not applicable

Referrer details (if different to above)

Referrer's name:

If you are completing this form on behalf of someone else, please state your relationship to them:

Referrer's role / position:

Ophthalmologist

Optometrist

OtherOther

Agency / organisation:

Referrer's Address:

Referrer address line 1

Referrer address line 2

Referrer suburb / town

Referrer state

Referrer postcode

Referrer's Email:

Referrer's phone

How did you hear about VisAbility?How did you hear about VisAbility?

Would you like to receive occasional VisAbility news and updates via email?

Yes, I'd like to subscribe

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Individuals, parents or carers

Eye specialists or allied health professionals

Client details

Next of Kin

Emergency contact

Diagnosis (Adult)

Diagnosis (Child)

Other diagnosis

Visual acuity (Adult)

Visual field (Adult)

Combination of visual acuity and visual field loss (Adult)

Test results (Child)

Eligibility criteria (Child)

Additional information (Child)

Relevant medical conditions

Nature of acquired brain injury

Medical history

Medical status

Degree of motor impairment

Degree of sensory - perceptual impairment

Degree of cognitive impairment

Daily living skills

Rehabilitation Status

Referrer details (if different to above)

Apply for Services

Individuals, parents or carers

Eye specialists or allied health professionals

Client details

Next of Kin

Emergency contact

Diagnosis (Adult)

Diagnosis (Child)

Other diagnosis

Visual acuity (Adult)

Visual field (Adult)

Combination of visual acuity and visual field loss (Adult)

Test results (Child)

Eligibility criteria (Child)

Additional information (Child)

Relevant medical conditions

Nature of acquired brain injury

Medical history

Medical status

Degree of motor impairment

Degree of sensory - perceptual impairment

Degree of cognitive impairment

Daily living skills

Rehabilitation Status

Referrer details (if different to above)