Skip to content

Donate

Home
About
Services
Training
Our Impact
Get Involved
Latest
Referrals
Contact

Home > Referrals

Referrals

If you know someone with sight and/or hearing loss, please use this form to refer them to our service. Vision & Hearing Support provides sensory services and information to people in Gateshead and South Tyneside. Please note that our hearing loss support is provided in South Tyneside only.

Step 1 of 2

50%

Has the person given permission for you to contact Vision & Hearing Support?

Yes

Contact details of the person making this referral

Name(Required)

Relationship / Profession(Required)

Telephone Number(Required)

Full name, address and postcode of the person you are referring

Name(Required)

Address(Required)

Telephone Number(Required)

Date of Birth(Required)

Email Address(Required)

Does this person live alone?(Required)

Yes

No

Does this person have support? (e.g. Family)(Required)

Yes

No

Are other services involved in this person's care?(Required)

Yes

No

Initial Communication Method(Required)

Phone

Large Print Letter

Email

SMS

Text phone

BSL

Other

Please specify method of communication(Required)

Please provide details of the eye condition / hearing loss(Required)

To help transition between services, what is the reason for the referral and what are the individual’s expectations of the service?(Required)

Are there any known issues that may pose a risk to our staff when working/ visiting the individual?(Required)

Yes

No

Please give details about the risk(Required)

GP Details

Attending Hospital Eye Services?(Required)

Yes

No

Where?(Required)

Any HES appointments or treatments due in the next two months?(Required)

Yes

No

Current Spectacles / LV Aids(Required)

Date of last eye test(Required)

Current eye test perscription(Required)

Please include the date and where the prescription was given

Do they have a Certificate of Visual Impairment (CVI)(Required)

Yes

No

Registration Status(Required)

Sight Impaired

Severely Sight Impaired

Attending Audiology services?(Required)

Yes

No

Where are they attending Audiology Services(Required)

Last Hearing Test(Required)

Do they have an Audiograph(Required)

Yes

No

Other Disabilities / Health Concerns / Hearing Loss(Required)

Are you aware if the person receives any benefits (such as PiP / ESA / DLA / Attendance Allowance)?(Required)

Yes

No

Please specify which benefits(Required)

Does this person have any aids / adaptations at home(Required)

Yes

No

Please specify home adaptations(Required)

Are there any concerns with the following

Managing at home (such as safe food and drink preparation, moving around, falls)

Accessing Information (such as safe food and drink preparation, moving around, falls)

Health & Wellbeing (such as safe food and drink preparation, moving around, falls)

Finance and Work (such as safe food and drink preparation, moving around, falls)

Getting out and about (mobility problems, access to transport, local groups)

Is the person able to go outside of their home(Required)

Yes

No

Any issues with mobility(Required)

Yes

No

Can they travel independently - use public transport?(Required)

Yes

No

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

About
Services
Training
Our Impact

Latest
Get Involved
Referrals
Contact

The Bradbury Centre for Sight
Unit 2B, Stonehills Business Centre
Gateshead
Tyne and Wear
NE10 0HW

Tel: 0191 478 5959

[email protected]

Registered Charity Number: 1107499 © Vision & Hearing Support 2024

Terms and Conditions
Privacy Policy
Web Design Newcastle by Urban River

Home
About
Services
Training
Our Impact
Latest
Referrals
Contact

This site uses cookies

We use cookies to give you the best browsing experience. We require your consent to store cookies for certain categories of functionality.

Required Analytics Marketing Third Party

More Info