Deaf-Blind Technical Assistance Request Form

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If you would like to receive free technical assistance for your child or a student who is deaf-blind (has a combined hearing and vision loss), please complete this form. Once this information is received, you will be contacted by a Colorado Deaf-Blind Project staff member to determine: (a) the type of technical assistance (TA) you need (b) what the specific need is, and (c) when is the best time to schedule the visit. If you have questions, call Gina Herrera at (303) 253-0451 or email her at herrera_g@cde.state.co.us

Email *

Your name: *

Today's date
*

YYYY

Phone number: *

School Address: *

Initials of the child that you would like assistance with (please use 1st two letters of first name and 1st two letters of last name. John Smith would be JOSM): *

Is the child on the Deaf-Blind Child Count (registry)?
*

Yes

Unsure

Required

Your relationship to the child: *

What format of Technical Assistance is needed?
*

Inservice

Home Visit

School Visit

Other:

Required

What is the frequency of needed Technical Assistance?

Consult/One Time Visit

Intensive Technical Assistance , up to 5 visits

More than 1 visit but fewer than 5 visits

I am not sure and would like to discuss options.

Other:

Has the school team that works with the child received the 2-hour training on deaf-blindness offered free by the Colorado Deaf-Blind Project? *

Yes, the entire team has taken the training

No, the entire team needs the training

Some or most of the team needs the training

Other:

What Topics Are You Interested In (check all the ones you are interested in for this child): *

Access to General Education

Auditory Training / Listening Skills

Assessment (vision, hearing, communication, development, or other)

Behavior Management (for problem or disruptive behavior)

Communication/Communication System Development (how to encourage a child to communicate)

Communication Matrix or other Types of Communication Assessment

Daily Living Skills (personal care and self help skills such as toileting, dressing, etc.)

Inclusion into School Program (techniques that support the child’s learning in the classroom)

Interveners (information, training)

Literacy Mode Determination (use of Braille, large print, etc.)

Medical Issues (gaining more information about a child’s diagnosed condition)

Orientation and Mobility Skills (movement and travel independence)

Organizing a Daily Routine (sequence of activities, transition from one activity to another)

Personal Futures Planning (a system of looking ahead and planning for the future)

Sensory Skill Development (vision, hearing, tactile skill use)

Social-Emotional Concerns (relationships with others)

Transition from Program to Program (e.g. preschool program to kindergarten program)

Transition from School into Adult Services (college, rehabilitation, group home)

Vocational Training

Other:

Required

Is there anything that you would like to add or explain? *

A copy of your responses will be emailed to the address you provided.

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