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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 Parent Guide
Guide By Your Side - Request a Parent Guide
Child Information
Child's Name:
Age/DOB:
Consultant:
Gender:
Consultant #:
Date of Entry:
Siblings:
Contact Information
Primary Parent Name(s):
Address, City & Zip Code:
County:
Phone:
Audiologist:
Email:
Hearing Level and Technology
Type
Sensorineural (SR):
N/A
Left Ear
Right Ear
Conductive:
N/A
Left Ear
Right Ear
Mixed (M):
N/A
Left Ear
Right Ear
Auditory Dyssynchrony AN:
N/A
Left Ear
Right Ear
Age Identified / Diagnosed:
Technology Used:
Degree
Typical (0-15):
N/A
Left Ear
Right Ear
Minimal (16-25):
N/A
Left Ear
Right Ear
Mild:
N/A
Left Ear
Right Ear
Moderate (41-55):
N/A
Left Ear
Right Ear
Moderate Severe (56-70):
N/A
Left Ear
Right Ear
Profound (91+):
Additional Information/Areas of Support
Comment:
Contact Us
Suite 3 #257, 60 Western Avenue, Augusta, ME 04330
207-570-5691
mainehandv@gmail.com