Visual Impairment Affirmative Counselling Request Form Student's Full Name * First Name Last Name Grade * City * Visual Impairment Diagnosis * Are you or Is the student registered with PRCVI (Provincial Resource Centre for the Visually Impaired)? * Please indicate whether the student is registered with PRCVI Yes No I don't know Student's Email * Student's Phone * (###) ### #### Reason for requesting counselling (select any or all that apply): Embarrassed to use assistive technology or white cane at school Afraid I’ll be rejected if kids at school find out I am visually impaired Frustrated that I’m not good at the sports we play in gym Sad or lonely because I don’t have friends at school Feel insecure about my appearance because I can’t see what others look like Hate asking for and/or accepting help Worried about my future and what job I’ll be able to do Rather not say Any other comments or questions Thank you. Your submission was successful. A counsellor will be in touch with you shortly to set up your first virtual meeting.
