North Dakota School for the Blind, Contact Us at the School for the Blind, Request for Services

Request for Services Infant/Student/Adult

Please complete the following information and press the Submit button at the bottom

Personal Information

Name:
Date of Birth:
Address:
City:
State:
Zip:
Phone:

Parent/Guardian

Phone:
Address:
City:
State:
Zip:

Referral Information

Referred by:
School/Agency:
Address:
City:
State:
Zip:
Occupation:
Phone:

Reason for Referral/Concerns:

Ophthalmologist/Optometrist

Name:
Office:
Address:
City:
State:
Zip:

Prior to delivering services the following information is requested:

Ophthalmology/optometric examination report from last visit.
Most current Functional Vision Evaluation.
Current IEP, IFSP, IHP or current progress/intake report.

Upon receiving the information, you will be contacted for scheduling. Please call or email if you have any questions.
1-800-421-1181 or 1-701-795-2700. djohnsen@nd.gov

As parent/legal guardian of the individual listed above, I authorize the service(s) indicated above to be completed. I understand the nature and purpose of these services.

Parent/Legal Guardian Name

Disclaimer

North Dakota Vision Services Contact Information for the School for the Blind

Request for Services Infant/Student/Adult

North Dakota Vision Services
Contact Information for the School for the Blind