Request for Infant-Toddler (Birth to 3) or Pre-School (3-5) Consultation This form may be completed by a parent, school district, ECI or other program staff. This type of consultation focuses on an individual infant or toddler (birth to 3) or preschooler (3 thru 5) and is related to specific programming concerns.General InformationConsultation Initiated By: Title: Work Phone: Cell Phone: Email: Name of DARS Contact: Name of TVI: Name of COMS: Name of teacher of deaf/hard of hearing: ESC Region: Family InformationParent/Guardian name: Email: Phone Number: Address including Street, City, State, Zip: Infant/Toddler InformationInfant/Toddler Name: Date of Birth: Cause of Visual Impairment or Eye Condition: Additional information about the child's visual impairment: Hearing Status Please select one of the following answers about the student's hearing. This will help us determine the best consultant to work with you for this consultation.Checkbox Group Has NO hearing problems Is labeled deafblind and is on the Deafblind Child Count Has a suspected hearing loss Wears a hearing aid or cochlear implant Has hearing loss in one ear onlyCause of hearing impairment (if applicable): Additional information about the child's hearing impairment (if applicable): If the child has an identified syndrome or condition such as CHARGE, SOD, Rubella, Pre-Maturity, etc., please include this information. Early Childhood Intervention Program: Home School District (if different): Has this child been seen by an ESC VI or Deafblind Consultant? Who? Other InformationWho at TSBVI Outreach have you contacted regarding your concerns? Primary Reason(s) for Consultation RequestReason for this Consultation Can you give examples of specific issues related to your concerns? What have you tried? What has worked? What hasn't worked?