Referral form: Adults

Thank you for contacting Sensory Services by Sight for Surrey. This form helps us understand how we can support you, or the person you are helping.

Before you start

You can use this form to:

To request support for yourself (self-referral), or
To refer someone else (with their permission)

If you are filling this in for someone else, please make sure they know and agree.

Your information and consent

We will keep your information safe and private. We only use it to understand your needs and give you the right support.

For more details, please read Sensory Services by Sight for Surrey Privacy Notice.

Self-referral only

Do you agree for us to use your information?

Yes No

Person being referred

Is the person being referred aware of and providing consent for this referral?

Yes No

Professionals only

Does the person know and agree to this referral?

Yes No

Details of the person who needs support (self-referral, or the person you are referring):

Name

Date of birth

Address

Postcode

Telephone/SMS

Are you/person being referred registered with a Surrey GP?

Yes No

Details of person referring (if not self-referral)

Name

Relationship to the person

Name of organisation (if applicable)

Telephone/SMS

Communication needs

Does the person needing support have any communication or language needs? For example: British Sign Language (BSL), lip reading, easy read, other language

Yes No

If yes, please tell us more

About you

Do you have a problem with your sight?

Yes No

If yes, please tick any that apply if you know your diagnosis

Cataracts Glaucoma Retinitis Pigmentosa (RP) Macular Degeneration (ARMD) Stroke-related sight loss (Sight loss from a stroke) Neurological condition (Brain or nerve condition) Diabetes-related sight impairment. Other/I do not know my diagnosis

If you answered other/I do not know my diagnosis, please describe

Do you have any difficulty with your hearing?

Do you use any hearing devices?

None Hearing aids Cochlear implant Bone Anchored Hearing Aid (BAHA)

Do you have a combined sight and hearing need?

Yes No

How can we help?

If you answered contact through a family member, friend, or carer, please provide details

Have you used our service before?

Yes No

If you answered no, how did you hear about us?

Optional: About you

You do not have to answer these questions, but they will help us improve our services if you do.

Your answers will not affect your referral.

Do you consider yourself to be disabled?

Yes No Not sure

Gender

Male Female Other Prefer not to say

Ethnic background

White

If you answered any other White background, please describe

Mixed or multiple ethnic groups

White and Black Caribbean White and Black African White and Asian Any other mixed or multiple background

If you answered any other mixed or multiple background, please describe

If you answered any other Asian background, please describe

Black, Black British, Caribbean, or African

Caribbean African Any other Black, African, or Caribbean background

If you answered any other Black, African, or Caribbean background, please describe

Other ethnic group

Arab Any other ethnic group

If you answered any other ethnic group, please describe

What happens next?

We will let you know we have received your form.

A member of our team will aim to contact you within 2 working days.

If we are busy, it may take a little longer but will contact you as soon as we can.