FInancial Assistance

* Required

Personal Information


Emergency Contact



You must meet all the following criteria to be eligible for Financial Assistance

Financial Information

Supplemental Income
Documentation Needed:
A copy of your last two pay check stubs
Documentation Needed:
Current year Federal 1040 tax return
Documentation Needed:
Unemployment benefits (check status)
Documentation Needed:
Social Security benefits (copy of check/letter from SSA)
Documentation Needed:
SRA grants and/or amount of food assistance

Rehabilitation Services

Please check all Services that you are Seeking or are Currently Receiving:
Low Vision Evaluation
OT Evaluation & Treatment
Orientation & Mobility
Assistive Technology
Have you sought other Funding Sources for what you are applying for? *


Are you interested in information about Support Groups? *
Are you interested in Employment at Envision? *
Are you interested in Volunteering at Envision? *


The Envision Low Vision Rehabilitation Center will not discriminate based on race, color, religion, gender, national origin, ancestry, veteran status, age, disability, or any other legally protected characteristics.

Completion of this form does not guarantee eligibility for Financial Assistance. Incomplete or inaccurate information may cause delay or cancellation of your application. Eligibility will be reviewed every six months. At your request you will have the opportunity to discuss the application or outcome with a staff member.

Please print this Physician Information form and have your doctor fill it out.

To the best of my knowledge, all of the information included on this form is accurate.