Apply for Services

Requesting low vision services and support from VisAbility is quick and easy.

Individuals, parents or carers

If you are an individual living with vision impairment, or a parent or carer of someone with low vision, please complete the enquiry form below and one of our friendly team will contact you to discuss your needs both now and into the future. Please answer as many questions as possible so that we can best know how to provide help.

Eye specialists or allied health professionals

If you are an eye specialist (eg. ophthalmologist, optometrist etc) or allied health professional (eg. occupational therapist, O&M etc), please complete our online referral form (low vision medical certificate) below to make a referral on behalf of your client.

Apply For Services (April 2023)
Please note that forms marked with an asterisk (*) are required.
Please let us know which best describes you:*
Is the person being referred 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.

Client details

Address line 1
Address line 2
Suburb / Town
This will be automatically calculated.
Australian residency status*
Is an interpreter needed to communicate with the client?*
Funding sources for referral (if applicable)

Maximum file size: 10MB

Next of Kin

Emergency contact

Diagnosis (Adult)

Age-related Macular Degeneration (wet/scar)

Age-related Macular Degeneration (dry/atrophy)

Diabetic Retinopathy

Retinitis Pigmentosa



Diagnosis (Child)


Cerebral Vision Impairment


Optic Nerve Hypoplasia

Visual acuity (Adult)

Best corrected distance visual acuity:

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

Visual field (Adult)

Peripheral field remaining in degrees from fixation:
Is the field of vision constricted to 10 degrees or less from fixation? (ie. 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?

Test results (Child)

Best corrected distance visual acuity:

Please indicate if visual acuity was measured with:

Peripheral field remaining in degrees from fixation:


Maximum file size: 3MB

Eligibility criteria (Child)

Please select the relevant statement:

Additional information (Child)

Relevant medical conditions

Nature of acquired brain injury

Has the client been assessed by an ophthalmologist or optometrist?

Maximum file size: 3MB

Maximum file size: 3MB

Medical history

General Practitioner's address:
General Practitioner's address:
GP Address line 1
GP Address line 2
GP Suburb / Town
GP State
GP Postcode

Medical status

Is the client medically stable?

Degree of motor impairment

Gait (aids):

Degree of sensory - perceptual impairment

Vision loss:
Other sensory loss:
Visual processing problems:
Inattention / neglect vision:
Inattention / neglect body:
Spatial orientation:
Ability to read:

Degree of cognitive impairment

Language receptive:
Language expressive:
Problem solving:
Attention / concentration:

Daily living skills

Making hot drinks:

Rehabilitation Status

What is the rehabilitation status of the client:
Is the client's rehab funded by a specific department? Please select:
Where is the client mobilising independently on foot?
What is the client's driver's licence status?

Referrer details (if different to above)

Referrer's role / position:
Referrer's Address:
Referrer's Address:
Referrer address line 1
Referrer address line 2
Referrer suburb / town
Referrer state
Referrer postcode
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