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TLVC Online Referral Form

Clinic Location

Medicine Hat, January 22nd	Calgary, February 7th	Red Deer, March 20th
Lethbridge, January 23rd	Edmonton, February 13th & March 19th	Grande Prairie, April 18th

Date Referral Was Completed

Person Submitting This Referral

First name
Last name
Email	Email is already used by another user
Job title
Phone 1

Student Information

Legal First Name	An answer is requiredLegal First Name
Legal Last Name	An answer is requiredLegal Last Name
Date of Birth (YYYY/MM/DD)	An answer is requiredDate of Birth (YYYY/MM/DD)

Parents/Guardians Information

Name	An answer is requiredName
Day Phone Number	An answer is requiredDay Phone Number
Evening Phone Number	An answer is requiredEvening Phone Number
Home email	An answer is requiredHome email

Please provide us information regarding the students educational programming

Grade or School Placement	An answer is requiredGrade or School Placement
Functional Academic Level	An answer is requiredFunctional Academic Level
Other information about student's academic program	An answer is requiredOther information about student's academic program

School Information

School District	An answer is requiredSchool District
School Name	An answer is requiredSchool Name
School Address & City	An answer is requiredSchool Address & City
Principal	An answer is requiredPrincipal
Classroom Teacher	An answer is requiredClassroom Teacher
Classroom Teacher Email	An answer is requiredClassroom Teacher Email

Other School Supports

Vision Consultant	An answer is requiredVision Consultant
Email	An answer is requiredEmail
Other Therapists Involved	An answer is requiredOther Therapists Involved
Email	An answer is requiredEmail
Learning Support Teacher	An answer is requiredLearning Support Teacher
Email	An answer is requiredEmail

Visual Information

Please include a copy of the most recent ophthalmological/vision teacher report, if available

Diagnosis/Eye Condition	An answer is requiredDiagnosis/Eye Condition
Distance Acuity	An answer is requiredDistance Acuity
Near Acuity	An answer is requiredNear Acuity

10.

Digital copies of reports can be uploaded here

First file	First file	Required
Second file	Second file	Required
Third file	Third file	Required

11.

Is this student currently a client of the CNIB?

Yes

I do not know

12.

Has the student previously attended TLVC

If yes, when:

13.

Does the student wear glasses?

14.

Does the student use optical devices (such as magnifiers, monoculars, etc)?

If yes, please list devices

15.

Does the student use assistive technology?

If yes, please list devices

16.

Describe the challenges that the student experiences that are related to vision loss:

17.

What does the student's school-based team hope to gain from the TLVC assessment process?

18.

Does the student have regular Orientation & Mobility instruction?

If so, how often?

19.

Does the student use a white cane?

20.

Does the student use an identification cane?

21.

Is the student involved in any school extra-curricular activities?

If yes, please list:

This personal information is collected pursuant to section 33(c) of the Freedom of Information and Protection of Privacy Act. This personal information is being collected to determine eligibility to participate in Alberta Education’s Travelling Low Vision Clinic (TLVC). The personal information will also be used and disclosed to the members of the TLVC team for the assessment and provision of educational programing for children and youth with low vision. The assessment report developed by the TLVC will only be shared with individuals approved by the child or youth’s parents or guardians. Questions regarding the collection may be directed to the Director, Learner Supports Branch, Alberta Education, 8^th Floor, 44 Capital Boulevard, 10044-108 Street, Edmonton, AB T6J 5E6 or by telephone at 780-422-5045.

(Dial 310‐0000 to be connected toll‐free from outside the Edmonton area.)

Please click on the icon directly below to submit your referral