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Intake Form for Deaf Mentor / Parent Advisor Services

Please complete the form below. Required fields marked with an asterisk *

Questions? Please contact Briella diaz at [email protected]

First Name*

Answer Required

Last Name*

Answer Required

Email*

Answer Required

City*

Answer Required

County*

Answer Required

Role to Child*

Answer Required

Parent

Legal guardian

Other:

Does your child have an identified hearing loss?*

Answer Required

Yes

Unsure

Pending audiogram

Are you available to meet on a weekly basis with a Deaf Mentor and a Parent Advisor for a total of 7 visits each month?*

Answer Required

Yes

Confirmation Email

Confirmation Email *

Email Required