EA and DHH Referral Form

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Please complete this form to the best of your ability.
If you don’t have the information, leave it blank or mark N/A for not applicable
Please submit at least 4 weeks prior to the IEP or assessment deadline when possible.

Section 1: Requested JTC Services

Deaf and Hard of Hearing (DHH) Services & Educational Audiology are two distinct services. They each perform their own separate assessment, report, and recommendations.

NOTE: For students with or suspected of having hearing loss- It is strongly recommended to include a JTC Deaf and Hard of Hearing (DHH) service provider in addition to Educational Audiology services (if your school district also contracts with JTC for DHH services)

Services

Deaf and Hard of Hearing (DHH) services

Educational Audiology Services

Educational Audiology Services(Required)

(Required)

Diagnostic Hearing Test

Review of Outside Records & Assistive Technology Recommendations

Functional (Aided) Listening Assessment

Hearing Device Check

Attendance at IEP Meeting(Required)

Virtual

In-person

If Possible, Date/s(Required)

Section 2: Student Information

Student Full Name(Required)

First Last

Date of Birth(Required)

Grade(Required)

School Site(Required)

District(Required)

When is the anticipated IEP due date?

Section 3: Parent/Guardian Contact Information

Parent/Guardian Name(s)(Required)

First Last

Preferred Language(Required)

English

Spanish

Other

Enter Other Language(Required)

Phone(Required)

Email(Required)

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Section 4: Reason for Referral

Check all that apply(Required)

Student failed a hearing screening

Student suspected of hearing loss

Student has established hearing loss but lacks recent testing (≥6 months)

Review of outside audiological reports needed

Functional listening (aided) testing requested

Educational Audiology consultation for HAT recommendations

Device/HAT troubleshooting or verification requested

Other

Enter Other Referral(Required)

Brief Description of Concerns / Referral Purpose(Required)

Section 5: Audiological Information

Most Recent Hearing Test Date

Results(Required)

(Required)

Results Attached

Results Unavailable

Upload Audiogram or Medical Records

Accepted file types: jpg, pdf, Max. file size: 200 MB.

Types of Hearing Device(s)(Required)

Hearing Aid/s

Bone Conduction Device

Cochlear Implant/s

None

Brand/Model (if known)

Section 6: Authorization

Submitted by(Required)

Title(Required)

Email

Date(Required)

Signature(Required)

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Please complete this form to the best of your ability. If you don’t have the information, leave it blank or mark N/A for not applicable Please submit at least 4 weeks prior to the IEP or assessment deadline when possible.