Referral into Services Form

Surname: (required)

First Name: (required)

Preferred Name: (required)

Title: (required)

First line address: (required)

Town: (required)

Postcode: (required)

Telephone number(s): (required)

Email address:

Date of Birth: (required)

Gender (required)

Ethnic Group (required)

Eye Condition (required)

Has the individual been certified as Sight Impaired (SI) or Severely Sight Impaired (SSI) by an Ophthalmologist? (this is not required to access CamSight’s services) (required)

Sight Impaired Severely Sight Impaired Not RegisteredNot Known

Is the individual registered with their local authority as SI/SSI?

Yes - with Cambridgeshire County CouncilYes - with Peterborough City CouncilYes - otherNoNot known

Reason for referral: (required)

Self-referral:

YesNo

Are you aware of any other current or recent referrals made on behalf of this person? Please include agency names and the purpose of each referral to help us coordinate support and prevent duplication.

Has the person consented to this referral?

YesNo

Name:

Telephone:

Mobile:

Email address:

Relationship to Service User:

Referrer Details

If NO: please provide details of relationship to the Service User

Organisation name and job title:

Name:

Telephone Number:

Mobile:

Email address:

Some CamSight services are provided in the client’s home by a lone worker. Are there any significant health or safeguarding concerns that CamSight should be aware of?

Referral into Services Form

Designated Contact Details: (if different from the Service User)