BCFH - Intake Questionnaire

  • Questionnaire

  • Please fill out this form. This information is entirely confidential.

    The following information will assist us in understanding your child and family's needs.

  • Your child was referred to our organization by:*

  • Family Information

  • What sex was your child assigned at birth?*

  • Please include information about the child’s parents and/or legal guardians

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  • Do you/your family have other children?
  • How many other children do you have?

  • Other than your child, is anyone in your family D/deaf or hard of hearing?

  • Our program strives to respect diversity. If you think it will help us better serve your family, please provide the following optional information:

  • Do you prefer to use an interpreter?*
  • Are there any other accessibility needs we should be aware of?*
  • An individual can self-identify as an Indigenous person if they believe they have Indigenous ancestry in their family tree (official documentation or paperwork is not required). By self-identifying your child as an Indigenous person, you may have access to a variety of supports and programs. By acknowledging your child’s Indigenous ancestry, you can help contribute to the delivery of services that are responsive, flexible, and accessible, and the development of strategic goals and policies. Please check if you self-identify your child as an Indigenous person (please check all that apply):
  • How do you identify yourself:

  • Has it been recommended that your child be fit with hearing equipment?*
  • What type of hearing equipment has been recommended?*
  • Has your child received their recommended hearing equipment?*

  • Medical History

  • For us to best serve your family, it is helpful if you can share the following information.

  • Were there any complications during the pregnancy or at birth?
  • Did your child have any pre-natal exposure to these substances? Please check all that apply.
  • Are your child's immunizations up to date?*
  • Does your child have any allergies?*
  • Has your child had any serious illnesses, accidents or hospitalizations?
  • Does your child have any ongoing medical conditions?
  • Has your child's vision been tested by an optometrist or ophthalmologist yet?
  • Does your child have any developmental challenges and/or any other specific diagnosis?

  • Other Support Services

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

  • Are there other people or community supports that you have found helpful and would like us to be aware of?

  • Permissions

  • If you consent to services, we will send you a written summary of our initial meeting that may contain sensitive information. Please indicate below whether or not you agree to receive this report via email.*

  • 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.

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