Forms

 Some forms can be downloaded in two formats (see below)--MS Word 2003 and PDF (which can be opened with Acrobat Reader). 

Hearing Screen/Rescreen Report - Word, PDF

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 - Word, PDF

Used by private providers to report diagnostic audiological evaluation outcomes and amplification selection outcomes.

EHDI Initial Hearing Aid Authorization Form (DHHS 3056)

Low-Tech Communication Device Funding Summary

High-Tech Communication Device Funding Summary

BEGINNINGS for Parents of Children Who are Deaf or Hard of Hearing, Inc.
This list will help you determine which office serves your county.

• Raleigh Office referral form
• Charlotte Office referral form

Early Intervention Program for Children Who are Deaf or Hard of Hearing

Children's Developmental Service Agencies (CDSAs)
The Referral Form should be faxed to the CDSA for the child's county of residence (see list).