Wufoo

IDB Submit a Referral

Please use this form to submit a referral to the Iowa Department for the Blind. Enter the name of the individual being referred to the Iowa Department for the Blind. We will contact the person refer to discuss our services, and answer questions. If you are not making a referral and only need program and/or service information, please call: 515-901-8621.

Receipt of the most recent medical eye report is required for eligibility determination. Do not submit the medical eye report with this referral. Please fax the report to 515-242-5781.

First Name *
Middle Intial
Last Name *
Preferred Name
(if different from legal First Name; please provide)
Date of Birth MM / DD / YYYY
(if unknown, please estimate age)
Street Address:
City
Zip Code
Which county do you live in? *
Phone Number * ### - ### - ####
Alternate Phone Number ### - ### - ####
Email

Please enter your email address.
Facility Name (if applicable):
Referral Source
Provide name, address and telephone number of person submitting this referral.
If other source, please explain.
Please provide name of person submitting this referral: * First Last
Please provide the phone number of the person submitting this referral: * ### - ### - ####
Who should we contact first about this referral? *
Individual being referred Person submitting referral
Please indicate best time of day to be contacted. *
How do you prefer to be contacted? *
Email Phone
Preferred language *
English Other
Preferred language if other than English

Please use this field to submit any other useful information.
Please check boxes for blindness training you want more information about (check all that apply): *
Library Services - braille, large print, or talking books Developing non-visual skills to adapt to vision loss. Additional information about services and referrals.
Does the individual being referred have a guardian? If yes, please provide name and contact information, if no, please write "NONE" *

Please use this field to submit any other useful information.
Additional Comments/Information
(Please share any additional comments/useful information or write “NONE”) *

Please use this field to submit any other useful information.
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