test Request for Services (wp forms) Please enable JavaScript in your browser to complete this form.Applicant's Name (required) *Applicant's Email (required) *Applicant’s Phone Number (required) *Applicant’s Date of Birth (required) *Applicant’s Eye Condition (required) *Does this individual live in Toronto or GTA?YesNoReason for ReferralNewly diagnosedSudden change in visionConcerns for safetyOtherWhy do you believe our rehabilitation services will benefit this person?Programs of interest and/or need (please select one or more)Adaptive Daily Living Skills: Instruction in home and personal management related to living with sight loss, selection and use of assistive technology, being a partner in advocacy, adapting activities of daily living and leisure such as cooking, cleaning, organizational skills and moreAssistive Technology: Training in the use of technology, such as screen-readers (JAWS, NVDA, voiceover), computer, laptops, smart phones.Community Engagement Services: Assists in connecting clients to resources in the community, such as Recreational Groups and Activities, Community Health Services, Addiction & Mental Health Services, Support to Organizations in providing Equitable and Inclusive Services to Persons with a Vision Disability.Community Engagement Support: Assists in connecting clients to resources in the community, such as recreational groups and activities, community health services, addiction & mental health services, support to organizations in providing equitable and inclusive services to persons with a vision disability.Mental Health: Mental health challenges such as anxiety, often arise with sight loss and encounters with systemic ableism and personal negative experiences. BALANCE offers access for clients to both individual (by referral only) and group counselling.Orientation and Mobility: Work with cane and guide dog users to develop strategies to travel safely in the community, including various cane techniques, sighted guide training, analyzing traffic and intersections.Name of person making the referralRelationship to applicant Is the individual aware of referral? YesNoSubmit