Initial Enrollment Form (fillable form online complete then print to hand in)



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Initial Enrollment Form (fillable form online – complete then print to hand in)
This packet contains information that we are required to have on file by the State as well information that as is critical in assuring your child is receiving appropriate and individualized programing. This packet must be completed prior to your child receiving services. If an item does not apply to your child, please write in “NA” for not applicable.

CHILD INFORMATION


Child’s Legal Name (Last, First, Middle) Click here to enter text.

Nickname: Click here to enter text.

Date of Birth: Click here to enter a date.

Gender: 

Child’s Street Address: Click here to enter text. APT No. Click here to enter text. Town, State Click here to enter text. Zip code Click here to enter text.

Race: (may select more than one if applicable) ☐Caucasian ☐ Black or African American ☐ Hispanic/Latino ☐ Asian ☐ Native Hawaiian/Pacific Islander ☐ American Indian/Alaska Native ☐ Multiracial ☐ Unknown ☐ Other

Does child have a hearing loss? ☐ Yes ☐ No ☐ Suspected but not diagnosed ☐ Unknown

Does child currently receive any early intervention services? ☐Yes ☐ No

If yes, Name of Early Intervention Agency: Click here to enter text. Town: Click here to enter text.

Name of Early Intervention Coordinator: Click here to enter text.
FAMILY INFORMATION
Parent/Guardian/Caregiver


  1.  Name (Last, First, Middle Initial) Click here to enter text.

Home Phone: Click here to enter text. Cell Phone: Click here to enter text. Work Phone: Click here to enter text. Email Address: Click here to enter text. Primary Language: Click here to enter text.

Home Address is: ☐ Same as student (If same, Skip to #2)

☐ Different than student:



Street Address: Click here to enter text. APT No.: Click here to enter text. Town, State: Click here to enter text. Zip code: Click here to enter text.

Student lives at this address (check all that apply) ☐M ☐ Tu ☐ Wed ☐ Th ☐ F ☐Sa ☐ Su




  1.  Name (Last, First, Middle Initial) Click here to enter text.

Home Phone: Click here to enter text. Cell Phone: Click here to enter text. Work Phone: Click here to enter text. Email Address: Click here to enter text. Primary Language: Click here to enter text.

Home Address is: ☐ Same as student (If same, Skip to #3)

☐ Different than student:



Street Address: Click here to enter text. APT No.: Click here to enter text. Town, State: Click here to enter text. Zip code: Click here to enter text.

Student lives at this address (check all that apply) ☐M ☐ Tu ☐ Wed ☐ Th ☐ F ☐Sa ☐ Su





  1. Are there any legal custody agreements?

☐No (skip to #4)

☐ Yes (If yes, please attach a copy of the legal document that supports custody.  This information is necessary and required by the State for the protection of children’s records, as well as to ensure that legal guardians receive appropriate correspondence and reports.  Thank you.)

☐ Joint physical custody ☐ Sole physical custody with: Click here to enter text.

☐ Joint legal custody ☐ Sole legal custody with: Click here to enter text.


Demographic information




  1. Primary language used at home 

    1. If “other: Click here to enter text.


  1. Total number of children in the home: 

    1. If “other”: Click here to enter text.


  1. Does the child qualify for the state Medicaid program? 


  2. Parental Hearing Status Since childhood 




  1. Other family members with hearing loss since childhood: 




  1. Mother’s Educational Level 




  1. Father’s Educational Level 




  1. Family Income: 


BIRTH AND DEVELOPMENTAL History





  1. Child was born (in weeks) at: 

  2. Child was born at :

☐Hospital/Birthing Center: Please provide name, Town and State. Click here to enter text.

☐ Home: Skip to question 6



  1. Was your child discharged from the hospital with their mother or did they require a stay?  

☐Discharged with mother

☐Required NICU (Neonatal Intensive Care Unit) stay (length of stay Click here to enter text.)

☐Required hospital stay (length of stay Click here to enter text.)


  1. Did your child pass the newborn hearing screening? ☐ Yes ☐ No ☐ Unknown ☐ Did not have one

  2. Age (in months) at what age your child (approximately) began to do the following:. If your child has not yet accomplished these tasks, enter “NA.”

  • Rolled over Click here to enter text.

  • Sat unsupported Click here to enter text.

  • Crawled Click here to enter text.

  • Walked Click here to enter text.

  • Toilet trained Click here to enter text.

  • Spoke first words Click here to enter text.

  • Two word phrase Click here to enter text.

  • Sentences Click here to enter text.   




  1. Do you have any other concerns about your child’s development (e.g.: sleep, feeding/eating, behavior)?     ☐ No    ☐ Yes           If yes, please explain.Click here to enter text.  

HISTORY RELATED TO HEARING LOSS




  1. Age hearing loss was diagnosed (years/months)? Click here to enter text.

  2. Age when first amplified (years/months) Click here to enter text.

  3. Do you have a copy of your most recent test result? ☐ No  ☐ Yes   If yes, please provide copy.  

  4. Where does your child receive ongoing audiological support (name and address)? Click here to enter text.

  5. Does your child have a known cause for hearing loss determined by a physician?

☐ Yes, diagnosis made by physician (go to #7)

☐No (Skip to # 8)

☐Suspected but not diagnosed (Skip to #8)

☐Unknown (Skip to # 8)



  1. If yes, select the known medical cause made by physician

☐ Connexin related hearing loss

☐ Cytomegalovirus (CMV)

☐ ECHMO

☐Enlarged Vestibular Aqueduct(s)



Genetic other than Connexin

☐Meningitis

☐Microtia/Atresia

☐Mondini Malformation

☐Ototoxic Medication

☐Persistent Pulmonary Hypertension of the Newborn (PPHN)

☐Rubella

☐Syphilis

☐Other: Click here to enter text.


  1. Does your child have a known syndrome?

☐Yes, diagnosis made by Physician (go to #9)

☐No (Skip to #10)

☐Suspected but not diagnosed (Skip to #10)

☐Unknown (Skip to #10)




  1. If yes, select known syndrome diagnosed by physician

☐Alport

☐CHARGE


☐Cornelia deLange

☐Crouzon


☐DeGeorges

☐Down


☐Fetal Alcohol

☐Fragile X

☐Freidreich Ataxia

☐ Hunter/Hurler

☐Pendred

☐Pierre Robin Sequence

☐Treacher Collins

☐Usher


☐Waardenburg

☐Other Click here to enter text.




10 . Has your child been diagnosed with any other disability(s)

☐Yes, diagnosis made by physician (go to #11)

☐No (Skip to #13)

☐Suspected but not diagnosed (Skip to #13)

☐Unknown (Skip to #13)
11. If yes, select other diagnosed disabilities:

☐ Apraxia

☐Autism

☐ Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)



☐Blind/Cortical Vision Impairment

☐Developmental Delay/Disorder

☐Emotional Disturb/Mental Health

☐Oral motor

☐Orthopedic Impairment

☐Sensory integration

☐Specific Learning Disability

☐Traumatic Brain Injury (TBI)

☐Vision Impairment (corrected with glasses)

☐ Other Health Impairment (OHI)




  1. Rate the impact of the other combined condition (s), if applicable, that contribute to the child’s overall learning abilities 



AUDIOLOGY If you were able to provide the audiogram as requested on question #3 of this section, we can complete this section for you.



RIGHT EAR

  1. Right Ear: Degree based on Pure Tone Average (PTA) or ABR

PTA is average of responses at 500, 1000, and 2000 Hz

☐ Normal (0-14) (If normal, skip to Left ear questions)

☐Slight (15-25)

☐Mild (26-40)

☐Moderate (41-55)

☐Moderately Severe (56-70)

☐Severe (71-90)

☐Profound (90+)




  1. Right ear: Type of hearing loss 




  1. Right ear: Technology used 


If using CI:

a. Age when received (months) Click here to enter text.

b. Number of electrodes active if known: :

c. Has child had to have the Cochlear Implant (internal) Replaced? No ☐ Yes

If yes: Age when replaced (revised (in months) Click here to enter text.



d. Current Manufacturer of CI 

e. Sound processor name: Click here to enter text.

f. Electrode array name: Click here to enter text.

g. Sound processing strategy: Click here to enter text.


LEFT EAR

  1. Left Ear: Degree based on Pure Tone Average (PTA) or ABR

PTA is average of responses at 500, 1000, and 2000 Hz

☐ Normal (0-14) (If normal, skip #7)

☐Slight (15-25)

☐Mild (26-40)

☐Moderate (41-55)

☐Moderately Severe (56-70)

☐Severe (71-90)

☐Profound (90+)





  1. Left ear: Type of hearing loss 




  1. Left ear: Technology used 


If using CI:

a. Age when received (months) Click here to enter text.

b. Number of electrodes active if known:

c. Has child had to have a Cochlear Implant (internal) Replaced? No ☐ Yes

If yes: Age when revised (in months) Click here to enter text.



d. Current Manufacturer of CI 

e. Sound processor name: Click here to enter text.



f. Electrode array name: Click here to enter text.

g. Sound processing strategy: Click here to enter text.


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