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CAYSI Electronic Referral Submission
After a referral is received, Children and Youth with Sensory Impairments (CAYSI) consultants will contact the parent/guardian and person making referral as soon as possible.
If you have additional questions, please contact:
Jennifer Greiman at Jennifer.Greiman@ade.arkansas.gov or Brandey Burnett at Brandey.Burnett@ade.arkansas.gov

Student Name *
Date of Birth *
MM
/
DD
/
YYYY
Male or Female
Is there a documented vision loss? If yes, please describe
If there is no documented vision loss, please describe your primary vision concern. 
Is there a documented hearing loss? If yes, please describe
If there is no documented hearing loss, please describe your primary hearing concern. 
What type of assistance would be most helpful? *
Mark all that apply
Required
Teacher's Full Name
Teacher's Email Address
Type of Classroom/Setting
Is there anything else you would like for us to know? (i.e. Type of disability(ies) or suspected disability)
Is the parent/guardian aware of contact being made with CAYSI Project? *
Parent/Guardian *
Please include Full Name, Full Address with City, State and ZIP Code, Phone Number(s) and Email Address
What is the primary language spoken in the home? *
School/Agency (if applicable)
Please include Full Name, Full Address with City, State and ZIP Code, Phone Number(s) and Email Address
Person Making Referral *
Please include Full Name, Full Address with City, State and ZIP Code, Phone Number(s) and Email Address
How did you hear about CAYSI? *
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