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)
Person’s health card number
Person’s city
Person’s province
Person’s postal code
Person’s telephone number (day time or cell)
Person’s date of birth (YYYY-MM-DD)

1. How does the person’s vision loss impact their quality of life?
Safety
Job/Academic
Daily Living
Other Reason for the Referral
Other reason
2. Have they had a visit with their eye doctor in the last year?
Diagnosis
Eye Doctor’s Name
3. Is the person currently in a hospital or rehabilitation facility?
If yes, is this referral part of the discharge plan?
4. Is there additional assessment information to accompany this referral?
Rai HC/CHA
Health Care Assessment
Other
Other reason
5. Person’s preferred language
Enter other…

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

Alternate contact name
Relationship
Day time contact number

Referral Agency Information

Referral completed by
Name of person making referral
Organization/Relationship
Phone number
VLRC office closest to patient
Leave this field blank