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

A vision specialist, Ophthalmologist or Optometrist

Aged Care Assessor or Service Provider

Other: please specifyOther: please specify

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 client 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 the client of Aboriginal and/or Torres Strait Islander descent?

Country of birth

Language spoken at home

Is an interpreter needed to communicate with the client?*

Yes

No

If yes, please state which language:

Funding sources for referral (if applicable)

National Disability Insurance Scheme (NDIS)

Department of Veterans Affairs (DVA)

Insurance claim

My Aged Care / Home Care Package

I'm not sure, please contact me

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

Name of Support Coordinator

Name of Plan Manager

Please attach relevant documents including your: NDIS Plan, Modification reports, PBS Plan, etc. (max 10mb per file):

Maximum file size: 10MB

Name of HCP Provider

Name of HCP Coordinator

Name of Aged Care Assessor

Please attach any related documents of funding and diagnosis to this referral (max 10mb per file):

Maximum file size: 10MB

Disability and Health Information

Please let us know about your disability diagnosis:*

Reason for referral

Swallowing/Choking (Dysphagia)

Are there any difficulties with swallowing (dysphagia), such as choking, coughing, or feeling like food is stuck in your throat?

No

Yes, please describe the frequency and severity of these difficultiesYes, please describe the frequency and severity of these difficulties

If yes, are there any management plans or strategies in place to support during a swallowing or choking incident? If yes, please describe (or attach) these plans or strategies in detail.

Positive Behaviour Support

Are there any Positive Behavioural Support (PBS) plans currently in place for the individual?

No

Yes, please provide a brief description of the supportsYes, please provide a brief description of the supports

Please upload any relevant documents to your swallowing, Behaviour Management Plan or Interim Behaviour Support Plan

Maximum file size: 5MB

Name of person completing the form

First name:

Last name:

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

Agency / organisation you work for:

Your role / job title / position:

Email:*

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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Make a referral

Client details

Disability and Health Information

Swallowing/Choking (Dysphagia)

Positive Behaviour Support

Name of person completing the form

Section