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.

Please do NOT use Internet Explorer to complete this form. Please also do NOT use any autofill to complete fields - if you have any challenges submitting, please delete and type in (do not use autofill) the email fields.

Child's Legal Name

Child's Preferred Name (if different from legal)

Child's Date of Birth

mm/dd/yyyy

Child's Sex

Pronouns

Please type in if not found in dropdown

How would you like us to describe your or your child’s race/ethnicity

Please type in if not found in dropdown

Parent/Guardian Name(s)

Name & relationship of person completing the form

If different from parent/guardian

Home address

Cell phone number

Phone

Home phone number

Phone

Email address

Is your child in DCF care?

Yes

What service(s) are you looking for?

Please select all that apply

Speech-language evaluation

Psychological/Neuropsychological evaluation

Psychiatry evaluation

Audiology

Pre-surgical CI/BAHS evaluation (cochlear implant or bone anchored hearing system)

Not sure

What is your preferred location for speech and language services?

Select all of interest

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.

Yes

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

Medical History

Please describe the child's hearing levels

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

Does the child have any other medical needs?

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

Where does the child receive Audiology care?

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

List your questions, issues, or concerns below and how DHHP may be able to help you.

Birth History

Did you or your doctor(s) note problems with any of the following?

Select all that apply

Pregnancy

Labor

Birth

Was this child born full-term?

Yes

What was the age of the birthing parent at the time of the child’s birth?

What was the age of the non-birthing parent or partner at the time of the child’s birth? (if applicable)

If donor sperm or egg was used in the conception of the child, please state that below and include the age of the donor at the time of donation.

Did your child join your family through adoption?

Yes

Medical History

Has anyone in the family experienced the following

Select all that apply

Mental health concerns (anxiety, depression, etc)

Intellectual disability

Neurologic disease or disorder

Seizures/epilepsy

Please describe the mental health concerns, intellectual disability, neurologic disease or disorder, or seizures/epilepsy experienced by the family

Please describe the medical concerns indicated above

At what age did the child experience seizures, and are the seizures associated with a high fever?

Does this child complain of abdominal pains/vomiting?

Yes

Does this child complain of headaches?

Yes

Does this child have vision problems?

Yes

Does this child have any medication allergies?

Yes

Does this child have any other allergies?

Yes

Is this child currently taking any medications?

Yes

Developmental History

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

Or indicate if not yet reached

At what age did your child use their first words?

(spoken or signed)

At what age did your child first combine words?

(spoken or signed)

At what age did your child first walk?

At what age did your child first show use of fine motor skills?

e.g. fastening buttons, using zippers

At what age did your child first show use of early school-related skills?

e.g. reciting the alphabet, naming colors

At what age could your child first sit still for storytelling or television?

At what age did your child first socialize with other children?

At what age did your child first build with blocks or play with puzzles?

At what age was the child toilet trained for daytime hours?

At what age was the child toilet trained for nighttime hours?

Has this child experienced any sleep problems?

If so, please describe

Does this child show a clear hand preference?

Right hand preference

Left hand preference

No preference

Does this child mostly play with younger, older, or same-aged children?

Younger children

Older children

Same-aged children

Has this child ever received psychotherapy and/or counseling?

Yes

Family History

Who lives in the household with the child?

Please indicate their names & ages

Please indicate parent/guardian(s) occupation

What is the primary language in the home?

What is the primary language of the child?

Are any other family members D/deaf or hard of hearing?

Please describe if so

Has the child been seen by DHHP in the past?

Yes

Child Care

Is the child in a daycare setting? If so, where?

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

Yes

Early Intervention and Specialty Programming

Does/did your family participate in:

select all that apply

Early Intervention (EI) Programming

Specialty Service Programming for D/deaf and hard of hearing toddlers and families

Academic History

What is the name of the school or program that the child currently attends?

Please include the town

What grade is the child enrolled in?

Does the child receive any support in school?

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

Please describe the services received

Has the child received any school-related evaluations?

Please describe

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

Who referred you to DHHP?

Please list any other information you feel is important for DHHP clinicians to know before evaluating the child

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

If you would like to be added to the email distribution list for future events organized by DHHP, please list your email here

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.

Health insurance provider

Policy holder's name

Policy number for child

Primary care physician's name

Primary care physician address

Primary Care Physician Phone Number

Your insurance policy is a contract between you and your insurance company. Boston Children’s Hospital is not involved.

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.

Please check here to indicate you understand this

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