Alabama Hands & Voices Guide By Your Side Referral Question Title * 1. Name of Child Question Title * 2. Child's Date of Birth Date / Time Date Question Title * 3. Family Contact info Parent/Guardian Name Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 4. Families Preferred method of contact Call Text Email Other (please specify) Question Title * 5. Was your child identified as a result of the Alabama Newborn Screening Program? Yes No I don't know Question Title * 6. Please give a brief description of the child's hearing loss (is it bilateral, unilateral, the degree, etc.) and if your child has cochlear implants and/or hearing aid. Question Title * 7. Referring agency information Referring Agency Contact Company Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 8. Alabama Hands & Voices is a non-profit 501(c)(3) organization. Funding is provided by the Alabama Department of Public Health, the Alabama Department of Rehabilitation Services, chapter members of Alabama Hands & Voices and various individuals. Thank you for referring this family to be contacted by the Alabama Hands & Voices Guide By Your Side program. A Parent Guide will connect with the family soon. Done