Interpreter/CART Referral Request Form
If you need more information, here is our "Contact Us" link!
https://ndhhs.org/contact-us/
What service are you requesting?
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ASL/English Interpreter
CART (Real-time captioning)
Both
Requester's Information:
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Requester's Email:
*
example@example.com
Requester's Billing Information:
*
Request Date (Date Needed):
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-
Month
-
Day
Year
Date Picker Icon
Names of Deaf/Hard of Hearing Participants
*
Names of Non-Deaf/Hearing Participants:
*
FOR MEDICAL REQUESTS, include patient's DOB:
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Month
-
Day
Year
Date Picker Icon
Arrival Time (if different from start time, perhaps for Check In):
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Hour Minutes
AM
PM
AM/PM Option
Start Time:
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Hour Minutes
AM
PM
AM/PM Option
End Time:
*
Hour Minutes
AM
PM
AM/PM Option
Onsite Contact Information:
*
Onsite Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this request virtual (Zoom, Webex, GoogleMeet, etc?):
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Yes
No
If yes, please include remote access link here:
Will this be recorded?
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Yes
No
Type of Event (doctor's appointment, meeting, workshop, interview, etc.):
*
Event Description (follow up for Diabetes, HR meeting, child development workshop, etc.):
*
Additional Comments/Information:
** Thank you for your commitment to language access! **
Submit
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