Referral Form Updated

ChildVision supports children and young people with a visual impairment. Before submitting a referral, please review our eligibility criteria

All applications for a service in ChildVision must fit the following criteria

The applicant must have either

A visual acuity of 6/18 or less not corrected by glasses
A visual field loss
A neurological condition that impacts visual functioning e.g. Cerebral Visual Impairment (CVI)

or

A potential deterioration/progressive visual condition

Must be living in the republic of Ireland

If you are unsure, please contact ChildVision before submitting.

Eligibility acknowledgement(Required)

I understand the eligibility criteria above and wish to continue with this referral.

Applicant name(Required)

First Last

Date of birth(Required)

Address(Required)

Number / Street / Townland Address Line 2 Area / Town

County(Required)

Eircode / Postcode(Required)

Parent or Guardian contact name(Required)

First Last

Contact email(Required)

Enter Email Confirm Email

Contact phone number

Country Phone Number

Is the referrer different from the contact above?

Yes

No

Referrer name

First Last

Referrer organisation

Referrer email(Required)

Referrer phone

Country Phone Number

Please outline the diagnosed or suspected visual impairment and provide some information on how this is impacting the applicant.(Required)

Upload documentation(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 256 MB.

How can ChildVision support the applicant?(Required)

Accuracy declaration(Required)

I confirm that the information supplied is accurate to the best of my knowledge.

Review your answers

Please check the information you have entered on the previous pages before submitting this referral. Use the Previous button to go back and make changes if needed.

Referral Form

Referral Form

ChildVision Referral Form

Review your answers