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Parent Pupil Education Program (PPEP) Intake Form
For referral or enrollment into Louisiana's birth to 5 free early intervention program for deaf and hard of hearing children.
Please send a copy of the child's audiogram to
iperez@lsdvi.org
. Fax: 225-757-3486
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* Indicates required question
Email
*
Your email
Date:
MM
/
DD
/
YYYY
Child's Name:
Your answer
Child's date of birth:
MM
/
DD
/
YYYY
Child's gender:
Female
Male
Prefer not to say
Other:
Clear selection
Child's race:
White
Black
Hispanic
Asian
Native American/Alaskan
Hawaiian/Pacific Islander
Other:
Clear selection
Audiologist's name and number:
Your answer
Identification/Diagnosis (check if more than one):
Sensorineural
Conductive
Mixed
Auditory Neuropathy
Hearing Levels: RIGHT Ear
Typical hearing
Mild
Moderate
Severe
Profound
Other:
Hearing Levels: LEFT Ear
Typical hearing
Mild
Moderate
Severe
Profound
Other:
Parent/Guardian Contact information (include name, address, email, and phone):
Your answer
Comments or notes to PPEP:
Your answer
Please send a copy of the child's audiogram to
iperez@lsdvi.org
. Thanks!
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