New Customer Interpreting Request Form
Thank you for choosing Communication Services for the Deaf and Hard of Hearing (CSDHH) as your provider of American Sign Language interpreting services.

This form asks you for general information about your organization and your request for interpreting services. This will allow CSDHH to establish you as a customer in our database, and will allow us to begin securing interpreting services for your request. No credit card number or other payment information will be collected at this time.

Upon submission of this request, a PDF copy is automatically sent to our office as well as to the email address of the person requesting the service. We will then begin working on scheduling an interpreter(s). We will reach out to you with any further questions or to solicit additional details.

This form is to be filled out by the requesting/billable party; please do not fill out this form on behalf of someone else without their knowledge and consent.

Submission of this form, and receipt of the PDF copy in your email, is not confirmation of our ability to schedule the requested services, but rather documentation of our receipt of your request. We will respond to you via email in a timely fashion, and will strive to provide confirmation of coverage with as much notice as possible.

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Business/Organization Name *
The name of the office, organization, etc. that is requesting interpreting services.
Alternate Name
Is there another name your organization may be known as? (ex - you operate under a DBA, you recently rebranded, etc.). If not, leave blank.
Requestor information
The following 4 questions refer to a Requestor, who is the person making the interpreting request and setting up services (typically the person filling out this form). We will contact you as the Requestor in order to confirm appointment details, request any other logistical information (such as prep material like agendas and scripts, etc.), and finalize the scheduling of the interpreter(s).
Name of Requestor *
Requestor's Job Title/Role *
Requestor's email address *
Requestor's Phone Number *
In the format XXX-XXX-XXXX
Billing Contact Information
The following 4 questions refer specifically to a Billing Contact, which may or may not be the same as the Requestor above. The Billing Contact is the person who should receive our Policies and Agreement to Pay Packet to complete and sign, which includes cancellation policies, standard and non-standard billing hours information, mileage fees, etc. The Billing Contact is the person to whom we should submit an invoice, from whom we should expect payment to be remitted, and whom we can contact with any questions regarding billing and payment.

If this person is the same as the Requestor above, please feel free to leave the next 4 questions blank.
Name of Billing Contact
Billing Contact's Job Title/Role
Billing Contact's Email Address
Billing Contact's Phone Number
in the format XXX-XXX-XXXX
Should we also send a copy of the completed Policies and Agreement Packet to anyone else?
As a reminder, the Policies and Agreement packet includes cancellation policies, standard and non-standard billing hours information, mileage fees, etc. We will send a completed copy to the Billing Contact above; if this should be sent to anyone else (Requestor, Office Manager, etc.), please include their email address here (limit 1). Otherwise, feel free to leave this blank.
Request information
The remaining questions from here refer to the requested need for interpreting services.
Date of appointment *
MM
/
DD
/
YYYY
Start time of appointment *
Time
:
Approximate duration of appointment *
Name of Deaf/Hard-of-Hearing Person *
Date of Birth/Medical Record Number
For medical appointments, please provide a Date of Birth and/or Medical Record Number (we ask for this information because we may need to provide it to your staff if we call with any questions about the request, and in case you need it included on the invoice for interpreting services). If not applicable, leave blank.
Format of Appointment *
CSDHH can provide sign language interpreters on-site or via remote video platform. If you are requesting video interpreting services, our interpreter(s) can join a platform you host (ex. Doxy.me, Doximity, MS Teams, Webex, Zoom, FaceTime call, etc.), or we can set up the platform (Zoom, or our own secure web-based platform).
Will this event be live-streamed or recorded? *
Whether this is a presentation/lecture/event that will be live-streamed to or recorded for a closed group of attendees, or live-streamed to or recorded and made public to the general public, we need to know in advance in order to inform the interpreter(s) and for them to properly prepare.
Location/Platform *
If your appointment is in-person, please list the full address of where the interpreter(s) need to go (including street name and number, city, state, ZIP code, and any relevant suite number or floor). If your request is virtual, please state what platform(s) may be used, and whether you are hosting the call/platform or you need us to host the call/platform.
Type of appointment *
Appointment Specifics *
Please include a brief description of the appointment (e.g. reason for medical visit, type of meeting, topic of presentation, etc.). A clear and detailed description here helps us immediately begin to secure services that best fit your need. If this is a video interpreting request, please include the meeting link or other join info , and/or other information or instructions to set up video interpreting (ex. "Link will be sent day-of appointment, etc.").
Will your request occur in 48 business hours or less?
If so, please call our office at 336-275-8878 ext 1. (Go ahead and submit this form too)
Next Steps:
After clicking the Submit button below:
1) You'll receive a copy of this submission to the Requestor's email address you provided above.
2) We will email the Billing Contact with our Policies and Agreement Packet to establish your organization as a customer.
3) Once that's completed, we'll work with you to schedule services.

Thank you again for choosing CSDHH, and we look forward to working with you!
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