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Guide By Your Side Family Referral Form
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orm for DC or Maryland resident families. Families may also self-refer to the GBYS program. The GBYS Program Coordinators will contact the family and offer the services of the GBYS program as well as complete already-established follow-up procedures through the respective EHDI office in DC and Maryland. The Program Coordinator will assign a Guide to the family. The Guide will contact the family within 2 days of receiving the referral. The Program Coordinator will inform the Referring person/agency if a Guide have not received any response from the family after 3 attempts to contact.
All information shared here is confidential and only shared with assigned Guides and DC or Maryland EHDI.
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* Indicates required question
Email
*
Your email
CHILD IDENTIFICATION INFORMATION
Child's Legal Name (First, Middle, Last)
*
Your answer
CHILD IDENTIFICATION INFORMATION
Date of Birth
*
Your answer
CHILD IDENTIFICATION INFORMATION
Gender
*
Male
Female
Undetermined
CHILD IDENTIFICATION INFORMATION
Ethnicity/Race:
*
Your answer
Parent/Legal Guardian Name:
First & Last Name
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Your answer
Parent/Legal Guardian Phone Number:
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Your answer
Parent/Legal Guardian Physical Address & Ward #:
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Your answer
Parent/Legal Guardian Email Address:
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Your answer
Primary Language Spoken by Parent(s)/Legal Guardian:
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English
Spanish
Other:
REFERRAL INFORMATION
Name of Referring Person, Agency/Practice
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Your answer
REFERRAL INFORMATION
Phone Number of Referring Person
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Your answer
REFERRAL INFORMATION
Email Address of Referring Person
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Your answer
REFERRAL INFORMATION
Has a Diagnostic Audiologic Evaluation been completed?
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Yes
No
REFERRAL INFORMATION
Child’s Diagnostic Results:
Type: Conductive
Type: Mixed
Type: Sensorineural
Type: Auditory Neuropathy
Type: Left Ear
Type: Right Ear
Type: Both Ears
Degree: Normal
Degree: Slight - Mild
Degree: Moderate
Degree: Severe - Profound
Degree: Left Ear
Degree: Right Ear
Degree: Both Ears
Other:
REFERRAL INFORMATION
Has a referral been made to DC or Maryland's Part C Early Intervention?
*
Yes
No
If this is a self-referral, please read on: By checking this box, you provide consent for MD/DC H&V GBYS to share your information to your EHDI organization (DC or Maryland) for additional access to family support
I give consent to share my information to my respective EHDI organization.
I do not give consent.
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