LIGHTHOUSE OF THE BIG BEND
CLIENT REFERRAL FORM
(Revised 12/16)
Basic Information
Referral Date:______Referred By:______
Primary Staff at Application:______
Referral Phone #: ______
Client Name:______
Age: ____ DOB: ______
Street Address: ______
City: ______State: ____ Zipcode: ______County: ______
Home Phone:______Cell Phone:______
Email: ______
Mailing address if different from above: ______
City: ______State: ____ Zipcode: ______
Primary Contact Person:______Relation:______
Contact Home Phone: ______
Contact Work Phone: ______
Contact Cell Phone: ______
Contact Email: ______
What are your living arrangements?
☐ Live alone
☐ Live with spouse, significant other, or partner
☐ Live with personal care assistant
☐ Live in a group home
☐ Live in an assisted living facility
☐ Live with family or friend
☐ Live in an institutional setting (jail, hospital, etc.)
Categorize your Visual Disability:
☐Totally Blind
☐ Legally Blind
☐Severe Visual Impairment (progressive)
Date of Onset of Vision Loss: ______
Etiology: ______
Non-Visual Disabilities:______
Eye Doctor Name & Ph#:______
Medical Doctor Name & Ph #:______
Directions to Client’s Home:______
Contact Person, Relationship & Phone:______
Other Agencies Serving Client:______
I am interested in the following services:
Orientation & Mobility
Independent Living (18+)
Assistive Technology Services
Braille Instruction and Communication Services
Vocational Rehabilitation Services (employment related services)
Early Intervention (age 0-5)
☐Children’s Program (age 6-14)
Transition Services (age 14-21)
I am not sure
Preferred Document Format:
Regular print
Large print
Braille
Electronic
Tape
Personal Information
This information is for statistical purposes only and will not be used to determine eligibility for services. This information is required because it helps us receive grants that support the services we offer.
What is your gender?
☐ Female
☐ Male
☐ Non-binary/ third gender
☐ Prefer to self-describe ______
☐ Prefer not to say
What is your marital status?
☐ Single
☐ Separated
☐ Married
☐ Divorced
What is your preferred language?
☐ English
☐ Spanish
☐ American Sign Language
☐ Other ______
Are you a Veteran?
☐ Yes
☐ No
Are you a migrant or seasonal farmworker?
☐ Yes
☐ No
Are you a registered voter?
☐ Yes
☐ No
Race:
☐ American Indian or Alaskan Native
☐ Asian
☐ Black or African American
☐ Caucasian or White
☐ Native Hawaiian or Other Pacific Islander
☐ Not Available
Ethnicity:
☐ Hispanic or Latino
Citizenship:
☐ US Citizen
☐ Permanent Resident
☐ Undocumented
☐ Refugee/Asylee
☐ Student
☐ Work Permit
☐ Other:______
Highest level of education:
☐ No schooling completed
☐ Nursery school to 8th grade
☐ Some high school, no diploma
☐ High school graduate, diploma or the equivalent (for example: GED)
☐ Some college credit, no degree
☐ Trade/technical/vocational training
☐ Associate degree
☐ Bachelor’s degree
☐ Master’s degree
☐ Professional degree
☐ Doctorate degree
Number of Persons in Household:______
Gross Monthly Household Income:______
Have you recently been a victim of a crime? ____ (If yes, refer to Ability 1st)
Do you consider yourself a member of the Lesbian, Gay, Bisexual, Transgender (LGBT) Community?
☐ Yes
☐ No
☐ No, but I am an Ally
☐ Prefer not to say
Please return to:
Lighthouse of the Big Bend
3071 Highland Oaks Terrace, Tallahassee, FL 32301
Or Fax to (850) 942-4518
Or Email to;
THANK YOU!