test Request for Services (wp forms) – BALANCE for Blind Adults

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?

Reason for Referral

Why do you believe our rehabilitation services will benefit this person?

Programs of interest and/or need (please select one or more)

Assistive Technology: Training in the use of technology, such as screen-readers (JAWS, NVDA, voiceover), computer, laptops, smart phones.
Community Engagement Support: Assists in connecting clients to resources in the community, such as financial resources, community health services, housing resources.
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.
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 more
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.

Name of person making the referral

Relationship to applicant

Is the individual aware of referral?