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Refer yourself or a loved one

Have you or has someone you love experienced a loss of vision that's impacting your mobility or independence? If you or a family member needs our support, we're only a few clicks away. Please fill out the form below as best you can, and one of our friendly and experienced client navigators will be in touch with you within 10 days on average, and less if we believe you are in a crisis situation.

We encourage you to complete all fields on this form so that we can build the best possible rehabilitation plan for you or the person you're referring; however, only those fields marked with an asterisk (*) are required. If you need assistance filling out this form, give us a call toll-free at 1-844-887-8572.

If you prefer, you can download and complete an accessible version of the Community Referral Form (PDF) and send it by fax to 416-480-7700.

Person’s Information

Date of referral (YYYY-MM-DD) Date of referral (YYYY-MM-DD)

Person’s health card number Person’s health card number

Person’s legal name Person’s legal name

Person's address 1 Person's address 1

Person's address 2 Person's address 2

Person’s city Person’s city

Person’s province Person’s province

Person’s postal code Person’s postal code

Person’s telephone number (day time or cell) Person’s telephone number (day time or cell)

Person’s date of birth (YYYY-MM-DD) Person’s date of birth (YYYY-MM-DD)

1. How does the person’s vision loss impact their quality of life?

Safety - Have you had a fall recently within the last 3 months due to your vision loss? Safety - Have you had a fall recently within the last 3 months due to your vision loss?

Have you burned yourself due to your vision loss Have you burned yourself due to your vision loss

Job/Academic - Are you at risk for losing your job due to your vision loss? Job/Academic - Are you at risk for losing your job due to your vision loss?

Are you at risk for academic failure due to your vision loss? Are you at risk for academic failure due to your vision loss?

Daily Living - Have you taken the wrong medication due to your vision loss? Daily Living - Have you taken the wrong medication due to your vision loss?

Other Reason for the Referral Other Reason for the Referral

2. Have they had a visit with their eye doctor in the last year?

Yes

Diagnosis Diagnosis

Eye Doctor’s Name Eye Doctor’s Name

3. Is the person currently in a hospital or rehabilitation facility?

Yes

If yes, is this referral part of the discharge plan?

Yes

4. Is there additional assessment information to accompany this referral?

Rai HC/CHA Rai HC/CHA

Health Care Assessment Health Care Assessment

Other Other

Other reason Other reason

5. Person’s preferred language

English

French

Other (please specify)

Enter other… Enter other…

6. Has the person been made aware of this referral and provided their consent?

Yes

Date consent given (YYYY-MM-DD) Date consent given (YYYY-MM-DD)

If consent was provided by someone other than the person being referred:

Alternate contact name Alternate contact name

Relationship Relationship

Day time contact number Day time contact number

Referral Agency Information

Referral completed by

Agency/Worker

Self-Referral

Family Referral

Name of person making referral Name of person making referral

Organization/Relationship Organization/Relationship

Phone number Phone number

VLRC office closest to patient VLRC office closest to patient

Leave this field blank Leave this field blank

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