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​ 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 address 1
Person's address 2
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 - 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
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?
Daily Living - Have you taken the wrong medication due to your vision loss?
Other Reason for the Referral
2. Have they had a visit with their eye doctor in the last year?
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?
Health Care Assessment
Other reason
5. Person’s preferred language
Enter other…

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

Alternate contact name
Day time contact number

Referral Agency Information

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