BSBP Services Referral Form

The following information is necessary to establish a referral for Bureau of Services for Blind Persons (BSBP) services. Please complete the information below to include the name of the person requiring services and their contact information. Upon submitting the requested information, the individual or guardian of the individual requiring services will be contacted by a BSBP representative who will process your referral, provide additional program information, and assign a Rehabilitation Professional to further discuss service needs. If you are unable to complete this form, please reach out to BSBP at 1-800-292-4200.

Program information

*Select a program: Youth Low Vision: Provided to individuals from birth through age 13 with low vision assessments and wearable devices who are currently enrolled students or those participating in a qualified educational program (including home school, alternative school, and registered online school programs). Pre-Employment: Programming available to students aged 14-26 with a documented disability who are enrolled in high school or post-secondary education/training. Vocational Rehabilitation: Open to Individuals at least 14 years of age with a desire to be employed. Designed to assess, plan, and provide vocational rehabilitation services to eligible legally blind or visually impaired customers. Independent Living Older Blind: Designed for individuals age 55 or older, who no longer seek employment, but require rehabilitation consultation and instruction to maximize their ability to maintain their independence in the home and community. Independent Living Part B: Designed for individuals aged 14 or older who have significant disabilities, are unable to obtain employment, but desire services to live in the least restricted environment while being included in the community and enhancing their 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.

Personal information of the individual requiring services

*First name

*Last name

Middle initial

Date of birth

*Is the individual requiring 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 requiring services? Parent Guardian

*Parent/Guardian first name

*Parent/Guardian last name

Parent/Guardian 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?