Referral Form

If you would like to refer someone to the Society who may benefit from any of our services you will find attached 2 forms to assist us in the process of providing services. Of these forms one is required (Referral Form), which is electronically submitted, one is to be signed and returned via mail (Release of Information), and one is optional (Functional Referral Form) but will better assist us in determining the types of programs and services that may be of benefit and help.

The Referral Form is required and will initiate the referral and help us begin the process, please fill in as much information as you know about the person, and then click submit at the bottom of the page to send the referral directly to us.

We also prefer to have the most recent eye condition information from the individual’s eye doctor. Please click here to print out a Release of Information Form and have the person sign and return to:

Karen Spencer
St. Louis Society for the Blind and Visually Impaired
8770 Manchester Rd.
St. Louis, MO 63144

Release of Information, (Print, sign and return via regular mail, to obtain most recent information on eye condition and status)

Please click here for the REQUIRED Referral Form.

Use this form to email referral

*NOTE -- Email address must be provided!

Submitter's First Name:

Submitter's Last Name:

Submitter's Email: (REQUIRED)

Submitter's Phone Number:

Submitter's relationship to person:

Name of Person Needing Services:

Street Address:

City:

State:

ZIP Code:

Age:

Birth Date:

Home Phone:

Work Phone:

Eye Condition(s):

Other Health Condition(s):

Eye Doctor's Name:

Doctor's Work Phone:

Significate Other Person's Name:

Reason For Referral:

Is the individual aware of the referral:

If not, please advise them someone from the Society will contact them in the next few days.