INITIAL Student Referral to  MSDB Outreach Vision Services
Please complete this form and fax any medical /vision documents to MSDB 406-771-6164:
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Email *
If you know your Outreach Consultant, please select below:
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Does the student have a current eye report from an eyecare professional (Ophthalmologist or Optometrist)?
Signed District Release of Information
 *
Person making referral *
Email address and Phone number *
Student Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Student (Family) Address *
School or Part C name *
School Contact Phone number *
Does the student have a current:
 *
Check if the child has difficulties in any of the following areas:
Below are questions about areas of need. 
Appearance of the Eye and/or Visual behaviors
Fine Motor
Touch
Hand Eye Coordination and Reading
Hearing
Perceptual Motor
Behavior
Orientation and Mobility
What is your reason for this  referral? *
What happens after the form is complete?  
The Outreach Consultant assigned to your school district will contact the school and/or teacher to schedule an appropriate time for follow up and testing. The student will be observed during the school day and have assessment(s) completed by the TVI or O&M. Once testing is complete, a meeting will be held to discuss the findings of the assessment(s) and eligibility or accommodations if applicable for the student.
A copy of your responses will be emailed to the address you provided.
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