NH Deaf/Hard of Hearing Role Model Program Referral
Today's Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact information of the person completing the referral:
Child's Name:
First Name
Last Name
Child's Date of Birth:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Contact Information
Family’s primary language:
English
Other
If other:
Child's hearing history
Is the family receiving early intervention services?
Yes
No
If yes, what is the name of the early intervention program?
Family is interested in the following:
In-person visit with Deaf/Hard of Hearing role model
Virtual visit with Deaf/Hard of Hearing role model
Virtual events, e.g. Family Connection series
Playgroups
Connecting with our family coordinator
Unsure
The family would like to meet a Deaf/Hard of Hearing role model whose preferred communication mode is:
American Sign Language (ASL)
Bilingual/Bimodal approach of ASL and Spoken Language
Cued Speech
Listening and Spoken Language (LSL)
Multiple communication apporaches
No preference
Do we have your permission to communicate with NH's Early Hearing Detection & Intervention Program based at the NH Dept of Health and Human Services regarding your family's participation in our Program?
Yes
No
How did you learn about the Role Model Program?
Audiology office
Early Intervention Provider
NH's Early Hearing Detection and Intervention (EHDI) Program
Other
If other, please let us know:
Submit
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