O&M Clinic Intake Form

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Please provide information below to be considered for orientation and Mobility (O&M) instruction, assessment, or other services through the University of Kentucky Orientation and Mobility Program. There will be an O&M session on March 26 in Lexington and May 21st or 22nd in Lexington or Danville.

Client's name *

If the student is under age 18, please provide the name and contact information for the parent/guardian.

What is the student's/client's age? *

Please provide an email address. *

Please provide a phone number for follow-up questions. 859-255-5467

In what Kentucky county do you live? Fayette

What services would the student/client be interested in? *

Receiving an O&M assessment

Receiving O&M instruction

Any workshops offered for O&M

Other:

Required

Would the student/client be able to attend an in-person event in one of the following locations?

Lexington -UK Campus

Danville, KY

Other:

Please describe the individual's eye condition (Including visual acuity and visual fields).

What would the client/student like to be able to learn or improve on with travel skills? *

Describe the home/residential environment (e. g. urban/rural, sidewalks present, pedestrian friendly). *

Does the student use a cane or other mobility device? *

Always uses a cane

Sometimes uses a cane

Uses an adaptive mobility device

Uses a dog guide

Never uses a mobility device

Other:

If they have received any O&M instruction, who is the individual's O&M instructor? Please provide an email as well if you have this information.

How does the client/student normally travel outside of the home? *

With friends or family using human guide

Independently using their cane or mobility device

Capable of traveling independently or with human guide

Other:

Describe the individual's level of independence. *

Are there any safety concerns regarding independent or assisted travel? Please be specific. *

Are there any health or medical concerns we should be aware of? Please be specific. *

Please include any additional comments here.

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