OUTREACH REFERRAL FORM
VISUALLY IMPAIRED PROGRAM

                  
Student’s Name ______________________________________________D.O.B. _____________ Sex ______________________
Parent/Guardian __________________________________________________Phone _________________________________
Street Address __________________________________ City ____________________________Zip Code _________________
School District Attending ______________________________District of Residence ___________________________________
School Attending ______________________________________ Phone _____________________________________________
Grade/Program __________________________________ ___    If Kindergarten:  am ______    pm______    full day ______ 
Other support service received ______________________________________________________________________________
CURRENT MEDICAL/EYE REPORT MUST BE ATTACHED SO REFERRAL CAN BE PROCESSED
Diagnosis _______________________________________________________________________________________________
Student’s Ophthalmologist/Optometrist ______________________________________________________________________
Primary reason for referral _________________________________________________________________________________
Does the vision interfere with student’s educational performance in their educational setting?
Yes ____   No ____  Explain _________________________________________________________________________________
REED date __________Latest IEPT date ___________Certification _________________________________________________
Parent has been informed of this referral: ____Yes     ___ No    Release of information has been obtained: ____ Yes   ____ No
Person referring ________________________________________ Title _____________________________________________
Location/Address ______________________________________________________Phone _____________________________

_________________________________________________________________________ Date _________________________
(Special Education Director, School District of Attendance)

________________________________________________________________________Date __________________________


(VI Intake)


PLEASE SEND THIS REFFERRAL AND ALL REPORTS TO:
Lincoln Park Special Services, Attn:  ___________________________VITC
2800 Lafayette, Lincoln Park, MI  481416
Phone:  313-389-0210     Fax:  313-389-0752