Deaf/Hard of Hearing and DeafBlind Services Referral — Online Form

Online Form

Professionals, agencies, or family members submit this form to refer a client to Therapeutic Services Agency's Deaf/Hard of Hearing and DeafBlind Services program serving Out-State Minnesota.

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Referral Information

Client Number

Date of Referral

Family Name

Client Name

DOB

Age

Sex

Race

Lives with

Previous TSA Client?

Last Date of Service

Family Member Names

Family Member Names	Age	Sex	Relationship to client

Client Address

Street

City

Zip Code

Phone

Okay to leave a message?

Phone

Okay to leave a message?

Primary reason for seeking services

Hearing Loss

Left Ear

Right Ear

Amplification

Vision Loss (complete if has combined hearing and vision loss (DeafBlind))

Visual Acuity

20/60 or less with eyeglasses

Visual Field

20 degrees or less

Degenerative Eye Condition

Cortical Visual Impairment

Communication

Receptive

Understands at age level?

Expressive

Speaks/signs at age level?

Diagnostic Assessment

Has a previous Diagnostic Assessment been completed?

Date completed

Who Completed the DA?

School

Name

Grade

IEP

504

Address

Other Service Providers

GAL

County Worker

Probation Officer

Psychiatrist

Insurance Information

Medical Assistance

ID#

Provider Name

ID#

Group #

Provider Phone Number (back of card)

Insured's Name

DOB

Employer

Referral Information

Name

Agency

Phone

Fax completed forms to 651-925-0071 or Email to info@tsapc.net. For additional information call or email Karen Sheldon, Clinical Supervisor, at 320-629-7600 ext 7921 or ksheldon@tsapc.net.

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Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.