Deaf Mentor Services - Intake Family Form
A Deaf Mentor provides family-centered, home based, and curriculum-led early education in the home, focusing on Visual Communication, American Sign Language, and Bridging and Navigating Deaf and Hard of Hearing Experiences with the families with deaf children, birth to age six (or beyond).  If you have any questions about the Deaf Mentor Services, please contact Kristy Griffin at Kristen.Griffin@christina.k12.de.us 
Sign in to Google to save your progress. Learn more
Email *
Your Name? *
Primary Phone Number? *
The Primary Phone Number is *
Required
Preferred Method of Contact? *
Street Address *
City *
State *
Zip Code *
Which County?
 *
Background Information about your child
Child's Name *
Child's Birth Date? *
MM
/
DD
/
YYYY
Child's Gender? *
Type of hearing abilities (loss)? *
Is your child using hearing technology? (I.e. hearing aid(s), BAHA, Cochlear Implant) *
If yes, what technology?
How do you communicate with your child? *
Are you currently applying or receiving services from any of the following programs? *
Required
Is your child attending a child care center? *
Your Availability
What is your family's availability for the initial visit with a Deaf Mentor?
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is there any other information you want to share with us about you, your child, or your family?
How did you learn about the Deaf Mentor Services?
The Deaf Mentor program is made possible by the Delaware's Early Hearing Detection & Intervention (EHDI), Delaware's Department of Public Health (DPH), and Health Resources & Services Administration (HRSA) grant.
Thank you for the information you have given us today. This will help us match you with a Mentor to begin working with your family. If you have any questions, please do not hesitate to contact Kristy Griffin, Deaf Mentor Services Coordinator at kristen.griffin@christina.k12.de.us
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Christina School District. Report Abuse
Google Forms