Please fill out this form to refer someone for vision rehabilitation services with BALANCE for Blind Adults. Be sure to learn more about our programs and services
before submitting a referral. When completing this form, provide as much information as possible to ensure we fully understand the referred individual’s needs. If you wish to have a consultation rather than lessons, please call the office and do not complete this form. Clients of BALANCE must:
- be 16 years of age or older,
- have a fixed address,
- be located in the City of Toronto, and
- have independent learning goals.
This personal health information is being collected under the authority of the Ontario Personal Health Information Protection Act (PHIPA), 2004 and will be used to determine eligibility for services at BALANCE for Blind Adults. All information collected is protected by the provisions of this Act.
For any concerns or questions regarding disclosure of this information, please call our main office at 416-236-1796 ext.0.
Alternatively, you may save this form and attach to an email. Email to: email@example.com
with subject line “Service Request”.
For more information or to register for BALANCE services, please email firstname.lastname@example.org
or call us at (416) 236 1796, extension 0.
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