Thank you for your interest in our program. We are here to help! So that we can best direct you to the programs and services your child needs, please take a few minutes to answer our intake questions. Any information you provide will be confidential. The more information you provide, the more quickly and accurately we will be able to process your request. If you are making a more general inquiry, please feel free to use the “Get in Touch” button. We look forward to connecting with you soon.

What is your first name?
What is your last name?
Email or Phone

Phone

Child's First Name:
Child's Last Name:
Child's Birthdate: Does your child have a hearing loss, or do you suspect they may have a hearing loss?
When was your child first diagnosed with hearing loss?
What degree of hearing loss does your child have in the LEFT ear?
What degree of hearing loss does your child have in the RIGHT ear?
When was your child first amplified (e.g., given hearing aids) in the LEFT ear?
When was your child first amplified (e.g., given hearing aids) in the RIGHT ear?
If your child uses a cochlear implant, when was the LEFT ear activated?
If your child uses a cochlear implant, when was the RIGHT ear activated?
Who is your child’s current audiologist?
What medical center or hearing center does your audiologist work at?
Does your child have any other diagnosis that you are aware of?
Does your child receive any services through the county or a school district (Please describe)?
Which county or district do you live in?
Has your child received other therapy services other than from the county/school district (Please list/describe)?
Please select the services you are interested in: (PLEASE HOLD YOUR KEYBOARD’S CTRL/CONTROL or COMMAND BUTTON FIRST AND THEN SELECT (ALL) YOUR CHOICES.)
How did you learn about our program and services? (PLEASE HOLD YOUR KEYBOARD’S CTRL/CONTROL or COMMAND BUTTON FIRST AND THEN SELECT (ALL) YOUR CHOICES.)
Do you have any other questions or comments?

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