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Newport City Council Social Wellbeing and Housing
Referral for Rehabilitation Services (Visual Impairment)
Personal Details
Title:
Gender: M/ F
First names:
Surname:
Address:
File Number:
Post Code:
Telephone:
Mobile:
Email:
D.O.B:
Age:
Living Situation
Lives alone: *Yes / No
If lives with others, who?
(Please give name and relationship)
Alternative contact details:
Vision:
Eye condition(s):
Field of vision:
Visual acuity:
Registration: Severe Sight Impaired/Sight Impaired/ Not
reg
Date:
(* Please circle as appropriate)
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General Health:
Hearing loss:
*Yes / No
If yes, can client hear on telephone?
Other disabilities / health conditions:
*Yes / No
General Practitioner
Name:
Address:
Tel:
Communication needs:
(Best way of contacting client)
*Standard print Large print (state size)
Braille
Fax
Minicom
Tape
Ethnicity:
First or preferred language: (state language eg. BSL,
Welsh)
Interpreter needed:
*Yes / No
Previous training: (please tick and give dates)
Mobility:
Independent Living Skills: (eg. cooking)
Communications: (eg. Braille, Moon, Low Vision Aids)
(* Please circle as appropriate)
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Training / Advice currently requested
(please tick)
Mobility
Communications
Living Skills
Guiding skills:
Low Vision Aids:
Indoor Mobility:
Braille/ Moon:
Outdoor mobility:
Handwriting:
Other:
Other:
(please state)
(please state)
Independent
Cooking:
Domestic skills:
Personal care:
Other:
(please state)
Social Worker’s comments:
(Please explain why you have ticked above section(s) –
this information will help with prioritising the referral)
Risk to lone worker: * Yes/ No
Referrers name:
Print name:
Referrers address:
Date:
Telephone:
(* Please circle as appropriate)
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Please send referral to:
Central Admin Adults
3rd Floor
The Corn Exchange
High Street
Newport
NP20 1RG
Or email centraladmin.adults@newport.gov.uk
(* Please circle as appropriate)
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