GBYS Professional Referral Page - Washington State Hands & Voices

Please contact the family...

Parent/Caregiver Name

Child's First and Last Name

First

Last

Child's pronoun

Child'd Date of Birth

Email

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter best day(s) and time(s) to contact the family.

Example: Saturday 10-11am OR Mondays 8-9am / Fridays 5-6pm

Best way(s) to contact the family.

Phone Call
Email
Text Message
Mail

Language(s) used at home

If "Other" list home language(s) in Comments section below.

Request Interpreting Services in Home Langauge

List home language(s) in Comments section below.

Ethnicity

Child's hearing level (Left ear)

Child's hearing level (Right ear)

Type of hearing loss / difference

Conductive
Sensorineural
Mixed
Unsure at this time

List Additional Diagnosis

Family Authorization

As parent and/or legal guardian of the child, I authorize WA State/County early intervention provider, Children with Special Health Care Needs provider, Family Resources Coordinator, Audiologist, Speech Language Pathologist, Teacher of the Deaf, Listening and Spoken Language provider, EI Primary Service provider, Specially Trained D/HH provider, or my primary care provider to release my name, address, phone number, and e-mail, along with hearing status and relevant family information, to Washington State Hands & Voices Guide By Your Side program so that I may receive information regarding Guide By Your Side program including resource information and parent support provided to families of children diagnosed with or suspect a hearing loss.

Today's Date

Relationship to Child

Referred by (Provider's Name)

Provider's Email

Provider's Phone Number

Provider's Role

If 'Other' list role in Comments section below.

Confirm referral was received

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Comments

NOTE: All information provided will be kept confidential. We will not disclose your personal information to a third party without your consent, unless we are required or authorized to do so by law or other regulation.