Refer someone to Full Circle Assistive Technology

One form for everyone — VR counselors, individuals referring themselves, schools, medical providers, family, agencies, and employers. Choose who you are and the form shows the right questions. Fields marked required are required.

I am referring as a… *

VR counselor

I am referring myself

School staff / Teacher of the Visually Impaired

Medical provider (eye doctor, OT, clinic)

Family member or caregiver

Community agency or program

Employer / other

About you

Your name *

Your email *

Your phone *

Agency / school / practice / organization

Your relationship to the person e.g., daughter, spouse, friend

Referral type

Note type

This determines your cost: below $2,000 per month, services are free; $2,000 and above, training costs $17.50 per hour.

Below $2,000 per month — free

$2,000 per month or more — $17.50 per hour

About the person you're referring

Their full name *

Date of birth

Their phone

Their email

Their address

Grade level

Parent / guardian name *

Parent / guardian phone *

Pre-employment transition services needed

For students with disabilities — check all that apply.

Job exploration counseling

Work-based learning experiences

Counseling on postsecondary opportunities

Workplace readiness training

Instruction in self-advocacy

What does this person need help with? *

Who should we contact first? The person themselves Me first

The person (or their guardian) knows about this referral and agrees to be contacted. *