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Referral Process for NMSBVI Low Vision Clinic Evaluation
and Downloadable Forms

Plan Ahead
Ideally, we ask that the completed registration paperwork be received by the Low Vision Clinic Coordinator four weeks prior to the clinic date. If that timeline is not possible, please contact the Low Vision Clinic Coordinator to discuss your needs to alter the referral schedule.

An initial clinical Low Vision evaluation usually takes about one and a half hours with the Low Vision doctor. Most students will then spend additional time with other clinic team members to do further follow-up with recommended optical devices, sunglasses, etc. The total time each student spends at the clinic could range up to three hours, depending on individual needs. Scheduling is usually done on a first come, first served basis as the completed forms are returned to the Low Vision Clinic (LVC) Coordinator. Please indicate if the student will be able to attend on "Thursday only" or “Friday only" for their appointment.

Complete and Submit
The teacher for students with visual impairments (TVI) or the certified  orientation and mobility specialist (COMS) typically initiates the referral to a Low Vision Clinic and serves as the contact person for the student’s educational team throughout the referral process. If a student has been identified as having a visual impairment, but is not receiving the services of a TVI or COMS, then another member of the educational team may initiate the referral process.

Print the Low Vision Clinic referral forms provided here, or contact the LVC Coordinator if you prefer having a printed packet of forms or individual forms mailed or faxed to you, or an electronic format emailed to you.

Form #1, the TVI Checklist, is provided to assist you with the referral process and does not need to be returned to the LVC Coordinator.

Complete and return forms #2, 3, 4, 5, 6, and 7 for each student you want to schedule. Contact the LVC Coordinator if Spanish forms are needed.

 

Downloadable Forms:

Consent to Photograph (Jan.2014)
Considerations for the Child Who Has Multiple Disabilities (Aug.2013)
LVC Consent Form
LVC - What Is It? Who Needs It? (Jan.2014)
Parent Pre-Exam (Jan.2014)
Privacy Practices Acknowledgement (Aug.2013)
Reasons for Students to Be Seen at LVC (Aug.2013)
Referral Process for NMSBVI Low Vision Clinic Evaluation (Jan.2014)
Student Pre-Exam (Jan.2014)
TVI Checklist (Aug.2013)
TVI Pre-Exam (Jan.2014)

Formas en Español (Jan.2014)

 

If you have any questions, or need further information or assistance with the referral process, please contact:

Valerie Tiensvold, NMSBVI Outreach
Phone:  505-859-0430
VTiensvold@nmsbvi.k12.nm.us

Kimber Kniffin
Outreach Dept. Administrative Assistant
Phone:  505-271-3067
Fax: 505-271-3073
KimberKniffin@nmsbvi.k12.nm.us

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