BCFH - Intake Questionnaire

Hearing and Hearing Aids
What have you been told about your child's hearing? (e.g. degree, type)*
Has it been recommended that your child be fit with any assistive hearing device?*

YesNo
What type of assistive hearing device was recommended?*
Has your child been fitted with the recommended assistive hearing device?*

YesNo
Date of Fitting

Communication
How do you usually communicate with your child?*
How does your child communicate with you? (eg. gestures, crying, pointing, facial expressions, sounds, talking, signing)*
Is there anything else you want us to know about your child’s communication or your concerns in this area?

Is your child receiving services from any other individuals or programs? Please check all that apply:

	Check if services provided
Infant Development Program
Physiotherapy
Occupational Therapy
Visual Impairment Program
Speech Language Therapy
Supported Child Care/Development
Preschool/Daycare/Childcare

If your child is receiving services from any service providers not listed above, please list them here:
Are there any people in your life or community supports or resources that you have found helpful to your family?

YesNo
Please tell us who else has been helpful to your family:

Permissions
I give my permission for my name to be added to a list of individuals who will receive future information, updates, and publicity from the BC Family Hearing Resource Society.*

YesNo
If you consent to services, we will send you an Intake Report that may contain sensitive information. Please indicate below whether or not you agree to receive this report via email.*

Yes, send the Intake Report by emailNo, do not send the Intake Report by email
Please sign here:*
My Name*

First NameLast Name
Today's Date*
FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPPA): The information requested on this form is collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be used only to facilitate the operation of our services/programs and is in compliance with the FIPPA. If you have any questions about the collection of your personal information, please contact us. Our head office address is 15220, 92nd Avenue, Surrey, BC V3R 2T8. You can also contact us by phone at 604-584-2827 (or toll-free at 1-877-584-2827), or by email at info@bcfamilyhearing.com.
Should be Empty:

BC Family Hearing Resource Centre Services Questionnaire