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Do you have a Deaf or hard of hearing child? Would you like support and resources?
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Request a Guide/ASTra Advocate
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Request a Guide/ASTra Advocate
Guide By Your Side - Request a Guide/ASTra Advocate
I am looking for a:
Parent Guide
D/HH Guide
ASTra Advocate
I was referred by:
Self
EIFS
NHS
Child Information
Child's Name:
DOB (mm/dd/yyyy):
Consultant:
Gender:
Consultant #:
Date of Entry (mm/dd/yyyy):
Siblings:
Contact Information
Primary Parent Name(s):
Address, City & Zip Code:
County:
Phone:
Audiologist:
Email:
Preferred method of contact:
Select an Option
Text
Call
Email
Any Method Works
Hearing Level and Technology
Type
Sensorineural (SR):
N/A
Left Ear
Right Ear
Both
Conductive:
N/A
Left Ear
Right Ear
Both
Mixed (M):
N/A
Left Ear
Right Ear
Both
Auditory Dyssynchrony AN:
N/A
Left Ear
Right Ear
Both
Age Identified / Diagnosed:
Technology Used:
Degree
Typical (0-15):
N/A
Left Ear
Right Ear
Both
Minimal (16-25):
N/A
Left Ear
Right Ear
Both
Mild:
N/A
Left Ear
Right Ear
Both
Moderate (41-55):
N/A
Left Ear
Right Ear
Both
Moderate Severe (56-70):
N/A
Left Ear
Right Ear
Both
Profound (91+):
N/A
Left Ear
Right Ear
Both
Additional Information/Areas of Support
Comment:
Contact Us
P.O. Box 406, Brewer, ME 04412
207-570-5691
mainehandv@gmail.com