Maine Hands & Voices - Maine Hands and Voices

Guide By Your Side - Request a Parent Guide

Child's Name:

Age/DOB:

Consultant:

Gender:

Consultant #:

Date of Entry:

Siblings:

Primary Parent Name(s):

Address, City & Zip Code:

County:

Phone:

Audiologist:

Email:

Type

Sensorineural (SR):

Conductive:

Mixed (M):

Auditory Dyssynchrony AN:

Age Identified / Diagnosed:

Technology Used:

Degree

Typical (0-15):

Minimal (16-25):

Mild:

Moderate (41-55):

Moderate Severe (56-70):

Profound (91+):

Comment: