Parent Survey

SoundBeginnings and Sound Start Parent Support Network Background Information Form

We know that it can be very helpful for families to connect by sharing resources, stories, and strategies when raising children who are Deaf/Hard of Hearing.
This network will match your family with other families based on the information you have provided.



           1. Name of Child
 
           First Name:

 
           Last Name:

 
2. Date of Birth:

           3. Gender:
Male
Female

           4. Caregiver(s) Name(s)
 
           First Name:

 
           Last Name:

 
5. Address:

 
6. Phone #:

 
7. Email Address:

           8.  What is your child's type of Hearing Loss? (Check all that apply)
Sensorineural (inner ear)
Conductive (outer or middle ear)
Mixed (combination of Sensorineural and Conductive)
Auditory Neuropathy

           9. Which ear(s)?
Right
Left
Both

           10. Pick the degree that best fits your child's hearing loss for the Right Ear:
Normal (0-20 dBHL)
Mild (21-40 dBHL)
Moderate (41-55 dBHL)
Moderate-Severe (56-70 dBHL)
Severe (71-90 dBHL)
Profound (90 dBHL or greater)
None

          11. Pick the degree that best fits your child's hearing loss for the Left Ear.
Normal (0-20 dBHL)
Mild (21-40 dBHL)
Moderate (41-55 dBHL)
Moderate-Severe (56-70 dBHL)
Severe (71-90 dBHL)
Profound (90 dBHL or greater)
None

 
12. Age Diagnosed with hearing loss:

 
13. Age fit with amplification (if applicable):

          14. What type of amplification does your child use (if any)? Check all that apply.
None
Hearing aid
Cochlear Implant
BAH(Baby BAHA or other type of bone-anchored hearing aid)

 
15. Who is your child's audiologist?


16. What is the primary language used in your home?

          17. What communication opportunities are you currently using with your child who is deaf/hard of hearing? (Check all that apply)
American Sign Language
Conceptual Signs (Pidgin Signed English or Conceptually Accurate Signed English)
Signing Exact English/Signed English
Spoken Language
Cued Speech
Gestures
Sign System
Fingerspelling
Home Signs
Listening
Speechreading/Lipreading

          18. What communication opportunities are you exploring? (Check all that apply) 
American Sign Language
Conceptual Signs (Pidgin Signed English or Conceptually Accurate Signed English)
Signing Exact English/Signed English
Spoken Language
Cued Speech
Gestures
Sign System
Fingerspelling
Home Signs
Listening
Speechreading/Lipreading

           19. What services has your child been involved in? (Check all that apply)
None
IFSP (infant/toddler services)
IEP (school services)
504 Plan
Other 

          20. Does your child have any additional disabilities? Is so, please list:

          21. What does your child enjoy doing?

          22. Would you be willing to have another parent/caregiver contact you?
Yes
No

          23. Would you be willing to contact another parent/caregiver?
Yes
No

          24. How would you like to be matched with other families? (Check all that apply)
Age of Child
Area in State
Type of Loss
Communication Opportunities
Type of Amplification
By All

          25. I would like to receive emails/information about upcoming events and resources in Kansas.
Yes
No

          26. By typing in my name below, I authorize the Programs to share my family’s contact information with other families of children who are deaf/hard of hearing in Kansas. This contact information will include my name, address, email address and telephone numbers. I understand that this information will be given only to Kansas families who have children that are deaf/hard of hearing and/or to the service providers who work with them. I understand that personal health information about those in my family will not be disclosed. I also understand that I can withdraw my consent in writing at any time.

Type name here.
Key in name.


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