I would like to be referred for a low vision assessment at a MABVI partnered clinic.
I would like to be referred for vision rehabilitation in my home with an occupational therapist.
I would like to participate in a low vision support group of my peers.
I would like to be referred for Orientation and Mobility services in my home or community with a certified Orientation and Mobility Specialist.
I would like a volunteer to assist with activities impacted by my eyesight.
I would like to become a volunteer with the blind and visually impaired.
I would like to be referred to a counselor to talk about my adjustment to vision loss.
Optional: You may choose to complete all or some of the information below to help us best serve you:
Referred by / Case Manager information:
By checking this box, I give my permission for MABVI staff members to contact my health care providers and insurance carriers for verification of information required and to share information in order to provide services requested.
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