Counselor Referral Form

* Indicates a required field

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.

Referral Date:

Referring Counselor:

Counselor

Counselor's Full Name

Email:

Office Phone Number:

Phone Extension:

Organization Fax

Counselor Mailing Address:

Address line 1:

Address line 2:

City:

State/Province

Postal Code:

Client

Client information:

First Name:

Last Name:

Nickname:

Does the client have an email address?:

Yes

No

Email:

Phone Number:

Client Home Address

Street Address:

Address Line 2:

Country:

City:

State/Province:

District/County:

Postal Code:

Medical:

Cause of Blindness:

Visual Acuity/Visual Field:

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

Secondary Conditions Checkbox:

Hearing Loss

Diabetes

Traumatic Brain Injury

Uses Mobility/Support Device (other than a white cane)

None

Other (Please explain below.)

Secondary conditions that may require accommodations:

Medical History:

Has the person ever been convicted of a crime?

Yes

No

Is the client subject to a conservatorship or guardianship?

Yes

No

Requires Language Interpreter Services:

Yes

No

Preferred Language

Skills:

Prior Blindness Skills Training:

Yes

No

Description of Prior Blindness Skills Training:

Primary Means of Independent Travel:

Uses White Cane

Uses Dog Guide

Travels without Mobility Aids

Does not travel independently

Educational / Vocational:

High School:

HS Diploma

GED

None

HS Year Completed:

Years of Post-Secondary training/education:

Certificates/Degrees Earned:

Most Recent Job Held:

Vocational Interests:

Behavioral:

Behaviors that may present barriers to employment:

Difficulty adjusting, keeping appointments, follow through:

Additional Information: