Sight Loss Self-Referral

Sight Loss Referral

Self-referral?

Would you like to complete the questionnaire?

General

How did you find us?
How would you like to be contacted?

Sessions?

What is the referral for?
If self-pay, which plan?
Preference? (multi-select)

Aspirations from counselling?

Address & Contact

GP Details

Home?

Employment?

Your Vision?

Vision Scale
Vision?
Reasoning?
Do you feel your vision loss is the basis of your mental health issues?

Mobility

Medical

What Would You Like Help With?

Mental Health Questions based on “you have or do you”?

Past Counselling?

Brief Summary