North Carolina Deaf-Blind Project

Family Contact Sheet

Family Information

Parents(s) Married/Divorced Name:

Address:

Lived at above address: ______months/years

Prior residence: (city/state) ______

Contact Information / Which is Preferred?
Home phone # / ( )
Cell phone # / ( )
Work phone # / ( )
Email address

Best time/day to contact family: ______

Sibling Information:

Brothers (name/age) / Sisters (name/age)

Child Information

Child’s name/nickname:

Age: Birthdate:

In brief, what you know about his or her vision (for example, what was the cause of the vision loss and what you think your child sees):

In brief, what you know about his or her hearing (for example, what was the cause of the hearing loss and what you think your child hears):

In brief, what do you know about his or her other disabilities and/or medical conditions (if any).

How does your child communicate with you? With others?

Child’s diagnosis: ______

Vision/Hearing: ______

Your child’s current educational services

Grade in school:

Child attends:

Elementary School / Middle School / High School

Type of classroom: (circle) Self-contained Inclusion Resource

Previous School(s):

Previous School / Reason for change

How are things going in their educational program? Are things going well? Are there challenges?

Types of Support You Would Like to Explore

1) Would like me to send you more information on:

_____ This year’s summer conference

_____ Written information about deaf-blindness or a certain topic you’re interested in

2) Would you like me to put your name on our family email listserv so you can interact with other families of children who are deaf-blind (does this exist???)

_____ Yes _____ No

3) Would you like me to put your name on our mailing list so we can occasionally send you announcements about activities or information about deaf-blindness?

_____ Yes _____ No

4) Would you like to set up a time to talk one-on-one and spend a little more time talking about your child, resources, or anything else.

How: (phone, face-to-face, etc)

When:

Where:

5) Would you be interested in getting together with other moms/dads, parents and/or families in your area who have children who are deaf-blind to share strategies, resources and support each other?

_____ Yes _____ No

Contact Log

Date / Type of Contact / Reason for Contact / Dialogue / Follow-up
F-2-F / Phone / Email / Mail