Refer a client, employee or student

Thank you for choosing to refer an individual to Vision Loss Rehabilitation Canada for support with their vision loss. We encourage you to complete all fields on this form so that we can build the best possible rehabilitation plan for the individual; however, only those fields marked with an asterisk (*) are required.

Please email us at info@vlrehab.ca​ if you have a problem submitting this form.​

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