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.
