Brent Visual Impairment Service (BVIS) Brent Civic Centre

5th Floor W Engineers Way

Wembley HA9 0FJ

Tel: 020 8937 3312 Email: paul.fielding@brent.gov.uk

Initial referral form

Name of person filling in form: Date:

Family name: First name:

Home address: Parent/Carer name:

Home phone: Mobile: Email:

D.O.B: M / F Position in family:

Ethnicity: First language: Interpreter needed: Y/N

Additional educational needs:

Educational setting: Key stage: School phone: Email: Contact name:

Statement/EHCP: Y/N TVI:

Medical information

Visual condition:

Hospital/Centre: Hospital number:

Specialist:

Associated medical condition (if any): Hospital/Centre: Specialist:

Is the child registered sight impaired or severely sight impaired? Y/ N If yes, which one?

I give consent for sharing information (including medical information) about my child with other involved professionals. This may involve sharing information with the local VI service outside Brent if your child attends school in another borough. Signature: Print name: Date: Relationship to child:

I would like to receive teacher of the visually impaired (TVI) visit records: Y/N If yes, please tick preferred method: Email Post

Brent Visual Impairment Service (BVIS) Brent Civic Centre

5th Floor W Engineers Way

Wembley HA9 0FJ

Tel: 020 8937 3312 Email: paul.fielding@brent.gov.uk

Medical Consent Form

Name of child: Date of birth: Hospital (where vision is checked): Name of consultant: Hospital number (if possible):

“I agree to the teacher of the visually impaired from the BVIS team having access to my child’s medical records” Name of parent/carer: Signature: Date: