Consultation Services Request Form – The Ohio Center for Deafblind Education

Consultation Services Request

"*" indicates required fields

Step 1 of 8 - Referral Information

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Referral Information

Child/student's name:*

First Last

Date of Birth*

MM slash DD slash YYYY

Parent/guardian's name:*

First Last

Parent/guardian's address:*

Address Line 1 Address Line 2 City State Zip

Parent/guardian's phone number:*

Parent/guardian's email:

Contact Information

Name of person requesting consultation:*

First Last

Relationship to the child/student:*

If other, please explain:

Phone:*

Email:*

Preferred method of contact:*

Best time to call?*

Does the parent know you are requesting a consultation?*

School/Agency Information

Name of school district:*

Name of school building/agency:*

School building/agency address:*

County:

Phone*

Request Information

Briefly describe the reason for requesting an onsite consultation:*

What type of information do you hope to get from this visit?*

Learn more about deafblindness

Information about teaching strategies (early intervention/birth through age 2)

Information about teaching strategies (preK through grade 12)

Information about additional services/accommodations to support the child/student

Information about communication techniques/strategies

Information that might be helpful to multi-factored evaluation teams

Please select up to three (3) choices

Please list the name and title of persons who plan to be present for the onsite consultation:*

Name

Title

Click the "+" sign to the right of the row to add an additional name/title. Enter as many as needed.

Please list other agencies that are currently working with this child/student:*

Related Services That the Child Is Currently Receiving

Services the child is currently receiving:*

Audiology Services

Speech/Language Pathology Services

Adapted Physical Education Services

Physical Therapy Services

Orientation and Mobility Services

Transportation Services

Interpreter Services

Medical Services

Occupational Therapy Services

Vision Consultation

School Psychological Services

Job Coaching Services

Paraprofessional (e.g., aide) Services

Intervener Services

Attendant Services

Guide Services

Reader Services

Other Services

Please click on all that apply

Other (please explain):

Information About the Child/Student

Level of hearing loss (without hearing aids or cochlear implant):

Left Ear*

Right Ear*

*Note: A child can be registered with OCDBE and receive services for one year if further testing is needed to verify and determine the nature of the child's hearing loss.

Does the child have auditory neuropathy?*

Does the child have Central Auditory Processing Disorder (CAPD)?*

What kind of sounds does the child/student respond to most frequently?*

Does the child/student use assistive technology for hearing?*

Level of vision loss (with correction):

Left Eye*

Right Eye*

*Note: A child can be registered with OCDBE and receive services for one year if further testing is needed to verify and determine the nature of the child's vision loss.

Does the child have Cortical Visual Impairment (CVI)?*

Does the child use assistive technology for vision?*

Information About the Child/Student (cont)

Communication modes used by the child/student to express himself/herself :*

Spoken language

Sign language

Body language, facial expressions

Behavior

Vocalizations

Touch cues

Object cues

Picture cues

Braille

Augmentative/Speech devices

Assistive technology

Other

Please click on all that apply

Other (please explain):

Communication modes used by individuals to communicate to the child/student:*

Spoken language

Sign language

Body language, facial expressions

Behavior

Vocalizations

Touch cues

Object cues

Picture cues

Braille

Augmentative/Speech devices

Assistive technology

Other

Please click on all that apply

Other (please explain):

Orientation and mobility modes used by the child/student.*

Independent in all environments

Uses a cane or other adaptive device

Independent in familiar environments with assistance in unfamiliar environments

Uses a dog guide

Uses a wheelchair

Assistance/Sighted Guide in all environments

Other

Please click on all that apply:

Other

Comments:

Self-Help Skills

Eating*

Toileting*

Dressing*

Bathing/Washing*

Oral hygiene*

Care of hearing aids, low vision aides*

Comments:

Assistive Technology used in the home, school. and classroom

Home*

School*

Classroom*

Additional Information we should know:

Is the child OLDER than 14 years old? If No, please skip to the next section.*

YES

Postsecondary Transition Information

Please complete the following information for any students ages 14-21 years of age.

Click the "+" sign to the right of the row to add an additional contacts. Enter as many as needed.

Name and contact information of individual(s) responsible for the student’s postsecondary planning*

Name

Phone

Names of agencies working with the student on postsecondary transition*

Student Postsecondary Transition Information

What aspirations does the student have related to:

Postsecondary training and/or education*

Postsecondary employment*

Postsecondary independent living*

What specific postsecondary information is wanted from the Postsecondary Transition Consultation?*

What postsecondary transition assessments have been completed for the student?*

What transition services does the student currently receive?*

What postsecondary transition resources are available to the student. Include volunteer experiences.

In the school*

In the district*

In the community*

What are the student’s interests?*

Describe the student’s work skills:*

What are the student’s accessibility needs?*

What is the student’s level of independence:*

Other (Please describe)

What are the parent’s/family’s postsecondary hopes for their child?*

Ready to Submit

Please note: A copy of the student’s IFSP or IEP will be requested to complete the consultation.

Signature (type your name):*

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Hearing Loss and Vision Impairment Assessments