Deaf Mentor Services - Intake Family Form
Delaware's Deaf Mentor Program follows the guidelines established by the Hands & Voices' Family Leadership in Language & Learning (FL3).  H&V Family, Language & Learning - FL3 (handsandvoices.org)

A Deaf Mentor provides family-centered, home based, and curriculum-led early education in the home, focusing on Visual Communication, American Sign Language, and/or Bridging and Navigating Deaf and Hard of Hearing Experiences with the families with deaf children, birth to age five (or beyond).  

This form is for families interested in receiving deaf mentor services.  The information will help us to assign the Deaf Mentor best suited for your family.  

If you have any questions about the Deaf Mentor Services, please contact Judy McGuigan at Judy.McGuigan@christina.k12.de.us 
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Email *
Your Name? *
Primary Phone Number? *
The Primary Phone Number is *
Required
Preferred Method of Contact? *
Street Address *
City *
State *
Zip Code *
Which County?
 *
Background Information about your child
Child's Name *
Child's Birth Date? *
MM
/
DD
/
YYYY
Child's Gender? *
Type of hearing abilities (loss)? *
Is your child using hearing technology? (I.e. hearing aid(s), BAHA, Cochlear Implant) *
If yes, what technology?
How do you communicate with your child? *
Are you currently receiving services from any of the following programs? *
Required
Is your child attending a child care center? *
Your Availability
What is your family's availability for the initial visit with a Deaf Mentor?
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is there any other information you want to share with us about you, your child, or your family?
How did you learn about the Deaf Mentor Services?
The Deaf Mentor program is made possible by the Delaware's Early Hearing Detection & Intervention (EHDI), Delaware's Department of Public Health (DPH), and Health Resources & Services Administration (HRSA) grant.
Thank you for the information you have given us today. We are looking forward to meeting you and serving your family.
A copy of your responses will be emailed to the address you provided.
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