Before we begin
Complete this form if you are requesting services for a family member, friend, or as a carer of someone who is 18 or older. You will be the primary contact person for this enquiry.
Fields marked with
*
are mandatory
Are they currently receiving services from Vision Australia?
Yes, they are an existing client
No, or I'm unsure
Do you have permission to submit this form on their behalf?
Yes, I confirm I have permission to submit this form on the person’s behalf
Be sure to obtain permission from the person before completing this form. Providing us their information confirms their agreement to discuss services and share personal information with Vision Australia. We handle information in accordance with our
privacy policy
.
Your details
Step 1 of 4
Step 1 of 2
Fields marked with
*
are mandatory
What is your relationship to this person?
Please select...
I am a child of this person
I am a spouse/partner to this person
I am a parent to this person
I am a grandchild of this person
I am a grandparent to this person
I am a sibling to this person
I am a friend to this person
I am their guardian
I am their power of attorney
I am a carer for this person
Other relationship
Your first name
Maximum 32 characters
Your last name
Maximum 32 characters
Your phone
Enter 10 digits without spaces starting with ‘0’ for mobile or phone with area code
Your email
If you do not have an email address, enter the email of a family member or carer, or call us on 1300 84 74 66.
Contact preferences
Do you require an interpreter?
Yes, for languages other than English
No, I do not require an interpreter
Select your preferred language
About the person
Step 2 of 4
Step 2 of 2
Fields marked with
*
are mandatory
Answer the following questions about the person for who you are completing this form.
Their details
Their first name
Maximum 32 characters
Their last name
Maximum 32 characters
Their date of birth (DD/MM/YYYY)
If you are under 18, a parent or guardian must complete a
Request services for my child
form on your behalf.
Their postcode
Maximum 4 characters
Their needs
What has prompted you to seek services on their behalf?
Please select...
They are newly diagnosed with a visual condition
They have deteriorating vision
A change in life situation where they need extra support
Seeking equipment to enhance their remaining vision
Other
Is there anything you would like to tell us about the person or this service request?
By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our
Privacy Policy
. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support
Their vision
Step 3 of 4
Fields marked with
*
are mandatory
What is their primary eye condition?
I don’t know their eye condition
Age-Related Macular Degeneration (ARMD)
Cataract
Diabetic Retinopathy
Glaucoma
Hemianopia
Macular Degeneration
Nystagmus
Retinitis Pigmentosa
Other eye condition
Enter their eye condition
What has prompted you to seek services on their behalf?
Please select...
They are newly diagnosed with a visual condition
They have deteriorating vision
A change in life situation where they need extra support
Seeking equipment to enhance their remaining vision
Other
Funding status
Step 4 of 4
Fields marked with
*
are mandatory
If the person is eligible for a funding source or government support (such as NDIS or My Aged Care) they need to access it to receive services from us. Alternatively, they can choose to speak to us about other options to access services.
Are they connected to a funding source or government support?
Yes, they have funding
No, they do not have funding
I'm not sure
Which organisation provides the majority of their funding?
My Aged Care, Home Care Package or they live in residential aged care
NDIS (National Disability Insurance Scheme)
DVA (Department of Veterans’ Affairs)
I’m not sure who provides their funding
Other
Enter details on who provides their funding
Their needs
Is there anything you would like to tell us about the person or this service request?
By submitting this form, you confirm that you agree to the storing and processing of your personal data by Vision Australia as described in our
Privacy Policy
. The information you have submitted will be used to provide you with the most relevant content on Vision Australia services, news & events, and other opportunities for support