BSBP Services Referral Form

The following information is necessary to establish a referral for Bureau of Services for Blind Persons (BSBP) services. Upon submitting the requested information, the individual or guardian of the individual requesting services will be contacted by a BSBP representative who will complete the referral, provide program information, and assign a Rehabilitation Professional to discuss service needs.

Personal Information of the Individual Requesting Services

*First Name

*Last Name

Middle Initial

*Date of Birth

*Is the individual requesting services under 18 years of age or over the age of 18 with a guardian? Yes No

Parent/Guardian Information

*Are you the parent or the legal guardian of the individual requesting services? Parent Guardian

*First Name

*Last Name

Middle Initial

Contact Information

*Primary Phone Number

*Email Address

*Street Address

*City

*County

*State

*Zip Code

Communication Preferences

*Select your primary language (select all that apply): American Sign Language (ASL) Arabic Chinese English French German Indian Japanese Korean Polish Portuguese Russian Spanish Vietnamese Other

*Specify another primary language:

*Select your preferred method of communication (select all that apply): American Sign Language (ASL) Braille Electronic Large Print Other

*What other method of communication would you prefer?

Program Information

*Select a program: Youth Low Vision: I am a parent or guardian of a child aged 13 or younger and wish to obtain wearable low-vision devices. Pre-Employment: I am a parent or guardian of a student aged 14-26 or I am a student aged 18-26 and am employment bound. Vocational Rehabilitation: I am 18 or older and desire employment services. Independent Living Older Blind: I am 55 or older and do not wish to obtain employment, but desire skills to retain independence in my home and community. Independent Living Part B: I am (or am the parent or guardian of an individual) aged 14 or older who has significant disabilities, am unable to obtain employment, but desire services to live in the least restricted environment while being included in my community and enhancing my quality of life. Information and Referral: I am a professional practitioner (education, medical, social worker, etc.) or family relative/friend requesting program information on behalf of the identified individual.