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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].

Role to Child*
Answer Required
Does your child have an identified hearing loss?*
Answer Required
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
Confirmation Email