Request for Student Consultation This form must be completed by school district, or other program staff. A student consultation focuses on an individual student ages 6 thru 21 and is related to specific programming concerns.School Coordination InformationConsultation initiated by: Title: Work Phone: Cell Phone: Email: Name of TVI: Name of COMS: Name of teacher of deaf/hard of hearing: ESC Region: Student InformationStudent Name: Date of Birth: Hearing StatusPlease 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.Hearing Status Has NO hearing problems Is labeled deafblind and is on the Deafblind Census Has a suspected hearing loss Wears a hearing aid or cochlear implant Has hearing loss in one ear onlyISD/Co-op/Agency School District (if different): Campus Name: Grade/Educational Placement: Cause of visual impairment or eye condition: Additional information about the student's visual impairment: Cause of hearing impairment (if applicable): Additional information about student's hearing impairment: If this student has an identified syndrome or condition such as CHARGE, SOD, Rubella, Pre-Maturity, etc., please include this information. Has this student been seen by an ESC VI or Deafblind Consultant? Who? Who at TSBVI Outreach have you contacted regarding this issue? Primary Reason(s) for Consultation RequestPlease indicate the top 3 areas within the child's programming you would like this consultation to focus on from the list below. Please do NOT select more than 3 areas.Areas of Concern Access to the General Education Curriculum Assistive Technology Issues Behavior Issues Calendars Routines Career and Vocational Skills Communication Skills Hearing & Listening Skills Literacy Skills Math Skills Motor Skills Orientation & Mobility Skills Independent Living Skills Recreation & Leisure Skills Self-Determination Skills Sensory Efficiency Skills Social Interaction Skills Tactile Skills Transition to Adult LifeAre there any other reasons for this request? Other InformationPlease share other information you think we should know. Can you give examples of specific issues related to your concerns? For example, the student is in algebra class and we are having problems adapting the program so it is fully accessible to him. (Please be as specific as possible.) What have you tried? What has worked? What hasn't worked? What do you expect as a result of this consultation? Family InformationParent/Guardian Name: Address including, Street, City, State, Zip: Phone Number: Email:
