Counselor Referral Form

Independence Training Program

Please complete the referral information requested below, then click the “Submit” button. At the end of the form, you can upload pertinent medical information, psychological assessments, work history or current client resume. However, you can submit the referral with or without uploading supporting documents and simply send them later.

Referring Counselor

Counselor's Name:*

First Last

Counselor's Email:*

Office Phone:*

Office Fax:*

Office Address:*

Street Address Address Line 2 City State ZIP Code

Client Information

Client Name:*

First Last

Does the client have an email address?*

Yes
No

Client Email:*

Phone Type:

Cell
Home

Client Phone:*

Client Address:

Street Address Address Line 2 City State ZIP Code

Medical Information:

Cause of blindness:*

Visual Acuity/Visual Field:*

How long has the client been blind/legally blind?*

Does the client have secondary conditions that may require accommodations during training at CCB:*

Yes
No

Please describe these secondary conditions:

Explain history of medical conditions, serious injuries, illnesses, or hospitalizations. Please include anything you feel will be important for the Colorado Center staff to know:

Social / Demographic

Date of Birth:*

Gender:

Male
Female

Primary Source of Income:*

What is your client’s marital status?*

Number of Dependents:

Please enter a number from 0 to 12.

Race/Ethnicity: How would your client describe him/herself?

American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White

What is the client's current living situation?

Has your client received any blindness skills training?

Yes
No

Briefly describe the training:

Primary Means of Independent Travel:*

Uses White Cane
Uses Dog Guide
Travels without Mobility Aids
Does not travel independently

Behavioral Observations

Does your client exhibit any behaviors that may present barriers to employment which should be addressed during his/her training program?

Has your client displayed difficulty adjusting to new situations, keeping appointments or following through? Please explain:

Educational / Vocational

High School:

HS Diploma
GED
None

Year Completed:

Years of Post-Secondary training/education:

Please enter a number from 0 to 10.

Certificates/Degrees Earned:

What was the most recent job your client held?

Vocational interests:

Additional Comments:

In the section below, please upload pertinent medical information, psychological assessments, work history or current client resume. Your client’s referral will be complete when we receive these supporting documents. If you can’t upload these at present, skip this section and go to the “Submit” button. you can fax or email these documents later: Fax documents to 303-778-1598 or e-mail them to ccb@cocenter.org to the Colorado Center for the Blind!

Upload File(s)

Drop files here or

Okay, all that’s left for this form is to hit the “Submit” button! Please call us at 303-778-1130 if you have questions of any kind. And thank you for referring your client.