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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 Information

Family Information

Infant/Toddler Information

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.

Other Information

Primary Reason(s) for Consultation Request