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 ndelgado@lsdvi.org and dtoups@lsdvi.org.
Email address *
Date:
MM
/
DD
/
YYYY
Child's Name:
Child's date of birth:
MM
/
DD
/
YYYY
Child's gender:
Clear selection
Child's race:
Clear selection
Audiologist's name and number:
Identification/Diagnosis (check if more than one):
Hearing Levels: RIGHT Ear
Hearing Levels: LEFT Ear
Parent/Guardian Contact information (include name, address, email, and phone):
Comments or notes to PPEP:
Please send a copy of the child's audiogram to ndelgado@lsdvi.org and dtoups@lsdvi.org. Thanks!
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