Forms

• Hearing Screen/Rescreen Report (PDF, 15 KB)
  • Used by birthing/neonatal facilities to report rescreen outcomes before birth discharge OR out-patient initial screen and rescreen outcomes.
  • Also used by any other provider to report initial screen and rescreen outcomes.
• Hearing Diagnostic and Amplification Report (PDF, 18 KB; Word, 35 KB) - Used by private providers to report diagnostic audiological evaluation outcomes and amplification selection outcomes.
• Permission for Referral Form
  • English (PDF, 10 KB)
  • Spanish - Autorización para remitir al paciente a otros servicios (PDF, 17 KB)
• BEGINNINGS for Parents of Children Who are Deaf or Hard of Hearing, Inc. This list (PDF, 32 KB) will help you determine which office serves your county.
  • Raleigh Office (PDF, 64 KB) Referral Form
  • Charlotte Office (PDF, 62 KB) Referral Form
• Early Intervention Program for Children Who are Deaf or Hard of Hearing
• Children's Developmental Service Agencies (CDSAs)
  • The Referral Form (PDF, 115 KB) should be faxed to the CDSA for the child's county of residence (see list).