Counselor Referral Form

* Indicates a required field

Independence Training Program

Please complete the referral information requested below, then click the “Submit” button. At the end of the form, you can upload pertinent medical information, psychological assessments, work history or current client resume. However, you can submit the referral with or without uploading supporting documents and simply send them later.

 

Referring Counselor:

Counselor
Client

Client information:

Preferred Pronouns:
Does the client have an email address?:

Medical:

Does the client have secondary conditions that may require accommodations during training at CCB?:
Secondary Conditions Checkbox:

Demographics:

CCB Demographics:
Gender
Requires Language Interpreter Services:
Is the client subject to a conservatorship or guardianship?:
Has the student ever been convicted of a crime?:
Primary Source of Income:
Marital Status:
Race/Ethnicity:

How would your client describe him/herself?

Check all that apply.
Prior Blindness Skills Training:
Primary Means of Independent Travel:

Behavioral:

Educational / Vocational:

High School: