Apply for Services

Applying for VisAbility services is easy. Simply fill in our online application form to apply for services or make a referral. You can also contact us to start your VisAbility journey today.

Apply For Services
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.

Personal Details

Address: *
Address:
Address line 1
Address line 2
Suburb / Town
State
Postcode
Gender:
This will be automatically calculated.
Australian Residency Status *
Funding sources for referral (if applicable)
Maximum upload size: 3MB
Are your contact details the same as the person being referred?

Alternate contact details

Alternate contact address:
Alternate contact address:
Alternate contact address line 1
Alternate contact address line 2
Alternate contact suburb / town
Alternate contact state
Alternate contact postcode

Diagnosis (Adult)

Age-related Macular Degeneration (wet/scar)
Age-related Macular Degeneration (dry/atrophy)
Diabetic Retinopathy
Retinitis Pigmentosa
Glaucoma
Cataract

Diagnosis (Child)

Albinism
Cerebral Vision Impairment
Nystagmus
Optic Nerve Hypoplasia

Other Diagnosis

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:
degrees
degrees
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?

Test Results (Child)

Best corrected distance visual acuity:
Please indicate if visual acuity was measured with:
Peripheral field remaining in degrees from fixation:
degrees
degrees
degrees
Maximum upload size: 3MB

Eligibility Criteria (Child)

Please select the relevant statement:

Additional Information (Child)

Social / Family Status

Is an interpreter needed to communicate with the client?

Relevant Medical Conditions

Nature of Acquired Brain Injury

Has the client been assessed by an Ophthalmologist or Optometrist?
Maximum upload size: 3MB
Maximum upload 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

Balance:
Stamina:
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:
Planning:
Initiation:
Attention / concentration:
Memory:
Insight:
Self-monitoring:
Impulsivity:

Daily Living Skills

Showering:
Toileting:
Dressing:
Eating:
Cooking:
Making hot drinks:
Cleaning:

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

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
Signature field