General Interpreting Request Form
Thank you for choosing CSDHH for your interpreting needs.

This form documents the details of your request for interpreting services, and is the first step towards securing said services.

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 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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Requestor information
The following 5 questions refer to the person who is requesting the interpreting service (the person filling out this form). We will contact you as the Requestor in order to confirm appointment details and scheduling of interpreter(s).
Business/Organization Name *
The name of the office, organization, etc. that is requesting interpreting services.
Name of Requestor *
Requestor's Job Title/Role *
Requestor's email address *
Requestor's Phone Number *
In the format XXX-XXX-XXXX
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)
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