Provider Referral Form

Please complete this form to refer a family to our Guide By Your Side program.

To access a pdf version of our Referral Form click on the links provided. English Referral Form | Spanish Referral Form

Once you have submitted your referral we will start reaching out to the family. For questions, contact Christine Griffin, Program Coordinator gbys@wahandsandvoices.org or (425) 268-7087.

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Child's First and Last Name
Address
Example: Saturday 10-11am OR Mondays 8-9am / Fridays 5-6pm
Best way(s) to contact the family.
If "Other" list home language(s) in Comments section below.
List home language(s) in Comments section below.
Type of hearing loss / difference
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.
If 'Other' list role in Comments section below.
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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.