Request for ASL Interpreting Services

Request for ASL Interpreting Services
Please note that interpreting services are fee based. To submit this request, you will be required to check that you have read and accepted our policies and procedures (provided at link in request form).

If you wish to verify the hourly rate before scheduling, please contact interpreting@bridgesfordeafandhh.org or 615.248.8828. You may also call your local office, but the main number canprovide rates for all areas.

IF THIS REQUEST IS WITHIN 48 HOURS OF REQUIRED SERVICE, PLEASE COMPLETE FORM AND CALL BRIDGESDHH'S INTERPRETING OFFICE AT 615.248.8828 TO CONFIRM RECEIPT.

Thank you for choosing BridgesDHH!
Which Area: West Tennessee & Surrounding Areas, Middle Tennessee & Surrounding Areas or East Tennessee & Surrounding Areas
Please note that BridgeesDHH provides services throughout Tennessee and surrounding states. The designations above reference the physical offices from which interpreters work.
Requester Name

First NameLast Name
Company/Business/Organization
Requester Phone

Area CodePhone Number
Requester Email
example@example.com
Confirm Requester Email
example@example.com
Requester Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you used our services before or do not need to update your billing information, please choose NO/BILLING UPDATE.
Billing Contact

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone Number

Area CodePhone Number
Billing Email
example@example.com
PO or Routing Code Number
Can the invoice be emailed?
Type of Services Requested
Service Context
Name of Deaf Client

First NameLast Name
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Start Time Interpreter Needed

:HourMinutesAM/PM Option
End Time Interpreter Needed

:HourMinutesAM/PM Option
Service Location
Name of school other location where services will be provided.
Timezone
Exact Address of Appointment

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parking | Driving Instructions
Any required dress code? If yes, please describe.
On-Site Contact

First NameLast Name
On-Site Contact Number

Area CodePhone Number
Please List ALL Individuals to be Present at Appointment and their Roles
If Requested, Name of Preferred Interpreter
Briefly describe the setting and what will be taking placewhen the interpreter arrives so that the interpreter may prepare for the assignment.
Is there anything else we need to know?
dress requirements, event to be videotaped, etc., agenda or program
Please click here to review our policies.

Our current rate sheets are available by request. Please contact interpreting@bridgesfordeafandhh.org.
Please click here and sign below to acknowledge you have reviewed and agreed to our policies. We cannot proceed with services without this acknowledgement. Please note that our policies include a cancellation/rescheduling policy because we are reserving and guaranteeing payment for the service provider's time. This policy applies regardless of whether the Consumer or Request cancels the job.
By signing below, you specifically acknowledge an understanding that all requests carry a 48-business hour cancellation policy. Any requests cancelled within 48-business hours of the start time of the request will be invoiced for services.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal

If a field is not applicable, please enter n/a
Case Number
Caption: X vs. Y
County
Court (e.g. General Sessions, Juvenile, Chancery, Circuit, etc.)
Court Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Case (e.g. criminal, civil, juvenile, etc.)
Charges
Courtroom
Judge
Plaintiff Attorney
Defense Attorney
Check-In Protocol
Parking Instructions/Availability
On-Site Contact Person
On-Site Contact Person Phone

Area CodePhone Number
On-Site Contact Person Email
example@example.com
Medical

If a field is not applicable, please enter n/a
DOB/MR#
Name of Medical Provider Patient is Seeing

First NameLast Name
What Will Patient Be Seen For?
Room/Suite/Floor
Will Appt Require a Male or Female Interpreter?
Specialty (e.g. Internal Medicine, OB/GYN, ENT, etc.)
Brief Description of the Appointment (consult, follow up, surgery, sick visit, pre op, post op, etc.)
Parking Instructions/Availability
If multiple entrances to the facility, which is the nearest to your office?
Mental Health

If a field is not applicable, please enter n/a
Patient MRN/File Number
Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Diagnosis(es)
Name of the Provider Being Seen

First NameLast Name
Parking Instructions/Availability
Should be Empty:

Request for ASL Interpreting Services

Legal

Medical

Mental Health