INFANT/TODDLER PRESCHOOL REFERRAL FORM
INSITE/VIISA Program
Date of Referral:
INSITEVIISA Program
West Virginia School for the Blind
301 East Main Street; Romney, WV 26757
Phone: (304) 822-4883; FAX (304) 822-4898
Email: doates@access.k12.wv.us or wmcdonal@access.k12.wv.us
Child's Name:
Sex:
D.O.B:
Social Security Number:
Parent's Name:
Address:
Telephone Number:
County:
Visual Condition (if known): Blind:
Partially Sighted:
Do you have a recent eye report (within 6 mos.) on file?
Referral Agent:
Name of Agency:
Address:
Telephone Number:
Is parent aware of referral?
Would parent be receptive to a home visit?
Other information:
This form should be accompanied by the most recent eye report
Referral form.doc revised Feb. 2005