Soundbridge Services Request Form 2023-2024
This form is to request services for a student who is new to Soundbridge services or needs additional services.  This is used to assist Soundbridge with the necessary information to identify the appropriate services needed and to create the necessary tracking data within our system.  
Email *
STUDENT DEMOGRAPHICS
Student's First and Last Name *
Student DOB *
MM
/
DD
/
YYYY
What school year is this intake for? *
Student's SASID or Birth-to-3 Case Number *
Student's home Address (street, apartment/unit, town/city, state, zip) *
District *
Does the student attend school in the same district checked above? *
Attending School Name - Please add district name if the school is in another district *
Parent / Guardian Full Name *
Parent Phone *
Parent / Guardian Email *
SCHOOL AND DISTRICT CONTACT INFORMATION
Your Full Name & Role *
Best contact for you (Email preferred) *
 Administrator's Full Name & Title (approver of referral) *
Best contact for administrator (Email preferred) *
EDUCATIONAL AUDIOLOGY SERVICES
Describe need for an educational audiologist consultation (e.g., determine candidacy for CAPD evaluation, review files and provide input to team on next steps, conduct educational audiology evaluation)

Please select all that apply

EDUCATIONAL AUDIOLOGICAL EVALUATION (Ruling in/out presence of student's educationally significant hearing loss and/or determining educational benefit with remote microphone hearing assistive technology  (RM HAT)

AUDITORY PROCESSING EVALUATIONS (Ruling in/out a student's auditory processing disorder. Educational Audiologist would determine candidacy prior to conducting the evaluation.

EDUCATIONAL AUDIOLOGY CONSULTATION (Determine need for and prescribe RM HAT, conduct staff training, or explain student's hearing loss)

504/IEP ATTENDANCE (Interpret audiological reports, describe educational impact, identify supplementary aids and services, assist in development of communication plan.)

CLASSROOM ACOUSTIC EVALUATION (Evaluation of noise, signal to noise ratio of teacher's voice and reverberation in classroom))
Select all audiology services:
TEACHER OF THE DEAF/HARD OF HEARING (TOD/HH) SERVICES
INITIAL EVALUATION (evaluate listening and language skills of student, assess communication competence of student with hearing loss, and distinguish learning challenges associated with student's hearing loss.)

DIRECT SERVICE (direct service in accordance with IEP/504 plan)

INDIRECT SERVICE (indirect service in accordance with IEP/504 plan)
TOD/HH service:
Please provide any additional comments or information needed to process this request
Please submit the following documents to SoundbridgeAudiology@crec.org
1. Current audiological report with audiogram (within 12 months)
2. Current IEP/504 Plan (within 12 months)
3. Parental Release form for Soundbridge to communicate with student's private audiologist 
3. Consent to Evaluate (for evaluation)
Additional: Relevant educational evaluations for APD (i.e., psychological evaluation, speech and language evaluation)
A copy of your responses will be emailed to .
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