Request for Service

Complete this form if you wish for a counselor to contact you regarding services.

First Name:    Last Name:

Address:

City:    State:    Zip Code:

Phone (Please include area code):

E-mail:

Birthdate:    Age:

Eye Condition (optional):

Amount of Vision (optional):

Other Known Disabilities (optional):

Other Information You Would Like to Share (optional):

By submitting this form electronically, I agree to have any or all of the information provided above be forwarded to a counselor that serves my area. All information will be treated as confidential.

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