Families Interested in the Role Model Program

Families Interested in the Role Model Program
Role models are available to families with children who are deaf or hard of hearing. Role models, who are deaf or hard of hearing, meet with each family, share their personal experiences, and serve as a positive influence in the lives of young children. Role models will also provide information on communication and language opportunities, like Listening Spoken Language, Cued Speech, Signed English and American Sign Language (ASL) and share ways to capitalize on residual hearing levels and access communication and technology tools.

Collaboration
Your Role Model will also collaborate with ECI, your teacher for the deaf through ECI (for children ages 0-3). The school districts for children who are ages 3 and up and will request your written consent to have this collaboration.
Are you willing to have your Role Model collaborate with your ECI team (for children birth-3)?*

YesNoMaybe
Are you willing to have your Role Model collaborate with your school-based team (for children ages 3 and up)?*

YesNoMaybe

Daily Life, Interests, and Activities
Please answer the information below. This will help us match you with a Role Model.
Please tell us about your child's daily routine, both Monday - Friday and on the weekends. We know sometimes routines change, but please tell us what you and your child usually do on these days. You can organize it by times of day, or just generally tell us what you do.*
What are some activities your child enjoys doing?*
What are some activities you and your family enjoy doing? Please include things you do both at home and outside of the home.*
Are there any other specific things you would like us to know about your family or your child?*

Availability
Because Texas is such a large state, some of our services will be face-to-face in your home, and some will be remote through services such as ZOOM, FaceTime, or other technology tools. Please answer the following questions about your availability and the days/times that will work best for your family.

Please tell us the top 4 days of the week that would be best for your family to meet with a Role Model.*

Please tell us the best times of day to meet with your family for each of your four choices.*

Our program will be conducted through remote sessions, are you willing to have meetings remotely (ZOOM, FaceTime, Skype)?*

YesNo
Are you comfortable using remote technology to meet with Role Models? (e.g., ZOOM, FaceTime, or other technology tools)*

YesNo
Do you have internet access in your home?*

YesNo
What kind of technology do you have available to you for remote services? (check all that apply)*

Computer (desktop with webcam or laptop)TabletVideophoneCell Phone

Additional Information
Is there any other information you want to share with us about you, your child, or your family?
Are you currently receiving services from other programs?*

YesNo
Which program(s) are you currently receiving services from?*
How did you hear about our Role Model program?*

Thank You!
Thank you for the information you have given us today. This will help us match you with a Role Model to begin working with your family.

If you have any questions, or if you wish to share any other information with us, please contact us at dhhm@tsd.state.tx.us.
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