To refer one of your patients for rehabilitation services at the Wisconsin Council of the Blind & VIsually Impaired please fill out the form below and submit it securely. You may also download the form and mail it in to 754 Williamson Street, Madison, WI 53703. Thank you.

First Name Last Name DOB

Address City State Zip

Phone Notes

DX:

BCVA Dist Near Near Visual Fields (please attach copy) OD OD Test Dist OD OS OS OS Test Dist OU OU Test Dist

Please provide: Training in sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands Training in self-care/home management training, e.g., activities of daily living, compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment Referral for or provide additional vision rehabilitation services as needed

Name Address City State Zip Phone E-mail Signature By Entering your name again in the signature box you are signing the form.