Deaf and Hard of Hearing Program Intake



The Deaf and Hard of Hearing Program at Boston Children's Hospital provides comprehensive evaluation and consultative services to deaf and hard of hearing children. We'll also interact closely with your child's physician, schools, and any other applicable agencies.


The information below will help make sure that your child is scheduled for appropriate evaluations according to their needs. Please complete this information to the best of your ability. You will be contacted once we have reviewed the information to schedule appointments.


Please attach in the field at the end of the form copies of the most current IEP or 504 plan and any evaluations/re-evaluations (speech-language, developmental, neurological, and cognitive/psychological) completed outside of Children’s Hospital.



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Is your child in DCF care?

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Psychology services are currently only offered in Waltham

Do you or the child need an ASL Interpreter and/or a spoken foreign language interpreter in a DHHP appointment?

Please be aware that the DHHP professionals are fluent in American Sign Language (ASL) and/or have access to the services of an ASL Interpreter.

The following information is helpful for your healthcare providers as they prepare for the child’s appointment

Medical History

e.g. moderate-severe hearing loss; mild sensorineural hearing loss, etc

e.g. Vision Loss, Autism Spectrum Disorder, Cytomegalovirus, etc

If the child is seen outside of Boston Children’s Hospital, please include any audiology, otolaryngology (ENT), speech-language pathology, or behavioral/developmental records.

Birth History

Select all that apply

The child being seen is the ___ of the mother's pregnancies
Was this child born full-term?
Did your child join your family through adoption?
Are medical records available from the birth country?

Medical History

Select all that apply

Please select all that apply

Does this child complain of abdominal pains/vomiting?
Does this child complain of headaches?
Does this child have vision problems?
Does this child have any medication allergies?
Does this child have any other allergies?
Is this child currently taking any medications?

Developmental History

For each section below, please indicate the age when your child first achieved each milestone

Or indicate if not yet reached

(spoken or signed)

(spoken or signed)

e.g. fastening buttons, using zippers

e.g. reciting the alphabet, naming colors

If so, please describe

Does this child show a clear hand preference?

Please list who if so

Does this child mostly play with younger, older, or same-aged children?
Does this child ever play with same age children?
Has this child ever received psychotherapy and/or counseling?

Family History

Please indicate their names & ages

Please describe if so

Has the child been seen by DHHP in the past?

Please describe

Please describe

Child Care

Is the child cared for by a sitter during the day?

Early Intervention and Specialty Programming

select all that apply

Where were services received?

At what age was this child enrolled?

What services does/did this child receive in EI?

Where were services received?

At what age was this child enrolled?

What services does/did this child receive in a Specialty Program?

Academic History

Please include the town

E.g. speech-language therapy, occupational therapy, etc

Please describe the services received

Please describe

Please also attach any completed evaluations in the section at the end of this form

Did you know DHHP coordinates Development and Training Workshops and Family Focused Outreach Events?

We will not in any circumstance share your personal information with other individuals or organizations without your permission

Financial/Insurance Information

If you have not yet been seen at Boston Children’s Hospital or if your child’s insurance information has changed, please complete this and include a copy of your insurance card.

If for any reason (including referral disputes) your insurance company does not pay your bill, you will ultimately be responsible.

All referrals/authorizations (when required by your insurance contract) must be in place prior to the patient’s appointment. A patient, whose family does not have their insurance referral and/or wishes to be seen outside their plan, may pay for their visit at the time of service.


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