PROJECT REACH REFERRAL

FORM A: INITIAL REFERRAL FOR
DETERMINATION OF ELIGIBILITY FOR SERVICES

Fill out the following form and click submit. Please provide adequate contact information.

All inquiries held in confidence.
 

Child's Information
 
Child’s Name:
Date of Birth:

Address:
City:
State:
  
Zip:
Home Phone:
County:

Current Program Information
 
School District/CFC:
Current Program/School:
Current Program Contact Name:
Phone Number:

Parent(s) / Caregiver(s) Information
 
Name(s):
  (mother)
 (father)
 (other)
Address:
(If different from above)
City:
State:
Zip:
Home Phone:
Work Phone:
Email:
Primary language
used in home:

Is there a legal guardian other than parents?       Yes     No

If so...

  
Name:
Address:
City:
State:
Zip:
Phone:

Deaf-Blindness
 
Cause of Deaf-Blindness
(if known):
* Vision Status
(if known):
* Hearing Status
(if known):

* Please attach the most recent vision and hearing diagnostic reports

Referrer Information
 
Name of person
submitting referral:
Agency:
Address:
City:
State:
Zip:
Phone:
 
How do you know child?
  
What do you need help with?
Is there anything else you
would like for us to know?


  

 

Home | What is Project Reach? | Who is considered Deaf-Blind? |
Deaf-Blind Specialists | Technical Assistance | How is a Referral Made? |
Philip J. Rock Center and School | Related Links | Contact Us


This site is Bobby Approved for accessibility.

Site Design & Hosting: Innovative Solutions for Business, Inc.