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Family Intake Form for Deaf Role Model Program

The Deaf Role Model (DRM) Program is formulated to provide support to families with deaf/hard of hearing children under the age of 3. This program entails 40 home visits per year by trained Deaf Role Models providing customized American Sign Language instruction, as well as tips on how to create a visual environment for the whole family. This is a joint venture between Deaf Counseling, Advocacy and Referral Agency (DCARA) and the Outreach Division of the California School for the Deaf in Fremont. This project is sponsored by the Newborn Hearing Screening Program Quality Improvement Collaborative.

1. Contact Info

First Name

Last Name

Title

Company

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Home Phone

Fax Number

Cell Phone

URL

2. I prefer to be contacted at my:

3. Name of your deaf/hard of hearing child: *This question is required.

4. Your deaf/hard of hearing child's date of birth: *This question is required.

calendar

5. Please list some of the best times for home visits with your family (Saturdays 10am-12, Thursdays 3-5pm)

1st choice
2nd choice
3rd choice
4th choice

6. Are you receiving services from Early Start (ages 0-3 years)?

7. Does your child participate in a Early Start playgroup?

8. Are you currently getting home visits from Early Start?

9. Who is your Early Start Teacher?

10. What is your current School District?

11. What languages are used at home?

1
2
3
4

12. List children living in your home:

Child's Name
Relationship
Age
Child's Name
Relationship
Age
Child's Name
Relationshp
Age
Child's Name
Relationship
Age
Child's Name
Relationship
Age

13. List adults living in your home:

Name
Relationship
Name
Relationship
Name
Relationshp
Name
Relationship
Name
Relationship

14. What else should we know about your family?

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