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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 for "First Name"

Last Name*

Answer required for "Last Name"

Email*

Answer required for "Email"

City*

Answer required for "City"

County*

Answer required for "County"

Role to Child*

Answer required for "Role to Child"

Parent

Legal guardian

Other:

Does your child have an identified hearing loss?*

Answer required for "Does your child have an identified hearing loss?"

Yes

Unsure

Pending audiogram

Please upload your child's audiogram to confirm that they have a diagnosed hearing level.

Upload Audiogram File

Answer required for "Upload Audiogram File"

Choose a file or drag it here.

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 for "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?"

Yes

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"