Refer a Child: A Shared Vision Support for Visually Impaired Children

We are your Early Intervention vision partner for very young children who are blind, deaf-blind, or visually impaired.

Three Easy Ways to Refer a Child

Choose one of three convenient options.

Whether you're with a Community Centered Board (CCB), an ophthalmologist, optometrist, primary care physician, another early intervention service provider, or a parent with concerns about a child's vision, you may refer a child to us in any of three ways. We'll respond to your referral within two business days.

Thank you!

#1. Complete Online Referral Form

Please note, it will be sent to A Shared Vision via an unencrypted service that is not HIPAA compliant.

Online Form

#2. Download and Email Referral Form

Complete the document and email it to us via your secure email service that is HIPAA compliant.

Download Form

#3. Request a Call Back

Request a call back for a confidential conversation.

Please Call Me

Refer a Child for Vision Services

We are your Early Intervention vision partner for very young children who are blind, deaf-blind, or visually impaired.

Three Easy Ways to Refer a Child

#1. Complete Online Referral Form

#2. Download and Email Referral Form

#3. Request a Call Back

A Shared Vision: Partners in Pediatric Blindness & Visual Impairment