DAQL REFERRAL FORM

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DAQL REFERRAL FORM

REFERRAL INFORMATION

Referring Agency/Organization

Referrer's Name
*

Referrer's Title/Position

Referrer's Phone Number
*

Referrer's Email
*

Date of Referral
*

YYYY

CLIENT INFORMATION

Client's Name
*

Client's Date of Birth
*

YYYY

Client's Address

Client's Phone Number

Client's Email
*

PRIMARY DISABILITY INFORMATION

Degree of Hearing Loss

Mild (26-40 dB)

Moderate (41-55 dB)

Moderately severe (56-70 dB)

Severe (71-90 dB)

Profound (91+ dB)

Unknown / Not specified

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Date of Onset

Birth

Early childhood (0-5 years old)

Childhood (6-9 years old)

Adolescence (10-19 years old)

Adulthood (20 years old and older)

Unknown / Not specified

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Cause of Hearing Loss

Genetic/hereditary factors

Congenital condition (present at birth)

Perinatal factors (occurring around the time of birth)

Illness or infection (e.g., meningitis, otitis media)

Noise exposure (occupational or recreational)

Traumatic injury (e.g., head injury, punctured eardrum)

Ototoxic medications (drugs that can damage the hearing system)

Age-related (presbycusis)

Unknown / Not specified

Additional Disabilities/Health Conditions

Visual impairment

Mobility impairment

Cognitive impairment (e.g., intellectual disability, traumatic brain injury)

Mental health conditions (e.g., anxiety disorder, depression)

Chronic health condition (e.g., diabetes, asthma)

Learning disability (e.g., dyslexia, ADHD)

Speech or language disorder

Developmental disability (e.g., autism spectrum disorder)

Neurological condition (e.g., epilepsy, Parkinson's disease)

Physical disability (other than mobility impairment, such as limb difference or paralysis)

Chronic pain condition

Respiratory condition (e.g., chronic obstructive pulmonary disease)

Cardiovascular condition (e.g., heart disease, hypertension)

Autoimmune disorder (e.g., rheumatoid arthritis, lupus)

Sensory processing disorder

Other:

COMMUNICATION PREFERENCES

Primary Language

American Sign Language

English

Spanish

Other:

Preferred Method of Communication

Sign Language

Speech

Lip Reading

Texting

Writing

Cued Speech

Other:

Communication Technologies

Hearing Aid

Cochlear Implant

Assistive Listening Devices or FM, Infrared of Audio Loop

Closed Captioning

Communication Access Real-Time Translation, or CART/Live Captioning

Captioned Phone

Sign Langage Interpreter

Videophone or Video Relay Services

Mobile or Smartphone Apps

Other:

Impact of Hearing Loss on Daily Life and Employment

Communication with Coworkers, Supervisors, or Customers.

Participation in Meetings or Group Discussions.

Verbal Instructions or Information.

Effective Use of the Technology Assistance.

Difficulties hearing alarms, warnings, or announcements in the workplace.

Issues with hearing and understanding in noisy environments.

Concerns about safety due to inability to hear environmental cues.

Anxiety or stress related to communication barriers.

Impact on job performance due to misunderstandings or missed information.

Limitations in accessing information during training or professional development sessions.

Difficulty networking or participating in social activities related to work.

Challenges in accessing accommodations or assistive technology in the workplace.

Impact on career advancement opportunities.

Struggles in job interviews or during the hiring process.

Overall impact on job satisfaction and retention.

Other:

Reason for Referral

Job placement assistance

Vocational skills training

Communication skills training (e.g., ASL interpretation, lip reading)

Assistive technology evaluation and training

Workplace accommodations assessment and implementation

Career counseling and guidance

Resume writing and interview preparation

Job retention support

Education or training program enrollment assistance

Transition services for students with disabilities

Support with self-advocacy and empowerment

Community resources referral (e.g., deaf and hard-of-hearing support services)

Vocational assessment and exploration

Support for entrepreneurship or self-employment

Other:

ADDITIONAL COMMENTS/INFORMATION

Family/Friend Support Available

Transportation barriers

Financial constraints

Preferred communication methods or accommodations

Previous experiences with vocational rehabilitation services

Specific vocational goals or career interests

Health Considerations Affecting Employment

Cultural or linguistic considerations

Legal considerations (e.g., disability rights, discrimination

No additional information at this time

Other:

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SIGNATURE OF CLIENT/PARENT/GUARDIAN/DATE

Please use your full name as signature and input the date below

Signature (Full Name in Block)

Date

YYYY

Submit

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This form was created inside of Makoto Ikegami.