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Who is making the referral?

Referrer Details

First Name

Last Name

What are your preferred pronouns?

Chosen Pronouns

Organisation / School

Your Position

Your Relationship to Student?

Your Relationship to person you are referring

Mobile or Landline

For landlines please add area code, please ensure that there are no spaces between the numbers.

Email

Do you have consent to make this referral?

Your Details:

Client/Student Details:

Title

First Name

Last Name

Gender Identity

How do you identify

Preferred pronouns?

Chosen Pronouns

Date of Birth

Please enter Date of Birth in DD/MM/YYYY Format Ex: 25/12/1980 for 25th of December 1980.

Identify as Aboriginal or Torres Strait Islander?

Is an Interpreter required?

Please state the Language

Contact Number

For Landline please include area code, please ensure that there are no spaces between the numbers.

Email:

Address:

Street

Suburb/City

Postcode

State

What assistance do you require from Guide Dogs Victoria?

Please provide information about their vision

What support would they like from Guide Dogs Victoria?

What support can Guide Dogs Victoria offer this student or your school?

Are you linked with any of these funding agencies?

Is the client linked with any of these funding agencies?

Other - Please specify

NDIS Details

Knowing a bit more about your NDIS Plan will help us process your referral more efficiently. You can tell us more about your Plan below. This is optional and you can provide as much or as little information as you like.

Knowing a bit more about the clients NDIS Plan will help us process the referral more efficiently. You can tell us more about the Plan below. This is optional and you can provide as much or as little information as you like.

NDIS Number

Plan Start Date

Plan End Date

How is the Plan managed:

Plan Manager (e.g. Maple Plan, Instacare etc.)

Would you like to share all or part of the Plan with us? You can upload below.

Funding Agency Details

Knowing a bit more about your funding will help us process your referral more efficiently. This is optional and you can provide as much or as little information as you like.

Knowing a bit more about the clients funding will help us process the referral more efficiently. This is optional and you can provide as much or as little information as you like.

Funding Number (The number that identifies with the agency)

Funding Agency Contact Name

Funding Agency Contact Number

Funding Agency Contact Email

Do you have additional medical information you would like to provide?

E.g. Medical Documents, Vision Condition Information

Additional Details

Do you have any relevant medical documents to upload?

Please select to upload relevant documents

Vision ReportDischarge SummaryOther Medical informationMedical Action Plans

Upload Vision Report

Upload Discharge Summary

Upload Other Medical Information

Upload Medical Action Plans

Date of diagnosis

Please enter Date in DD/MM/YYYY Format

Please provide details of their vision status:

Does the person use a mobility aid?

Please provide details

Is the vision status related to an Acquired Brain Injury?

Site of lesion (If applicable):

Cognitive impairment (If applicable):

Please provide details:

Is the person currently involved in therapy?

What therapy is the client currently involved in?

Please provide information about your vision

Where did you hear about us?

I would like to be added to the mailing list for "Perceptions".

Yes Guide Dog's quarterly newsletter for referrers

I would like to be added to the mailing list for "On The Move" and "Get About".

YesGuide Dog's bi-monthly newsletter for clients and guardians

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Contact Information

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