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About Your Family

Relationship to Child

Date of Birth

When was your child with hearing loss born?

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Year

Date of Hearing Loss Diagnosis

When your child with hearing loss diagnosed?

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Second Child

Date of Birth

When was your second child with hearing loss born?

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Date of Hearing Loss Diagnosis

When was your second child with hearing loss diagnosed?

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Third Child

Date of Birth

When was your third child with hearing loss born?

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Year

Date of Hearing Loss Diagnosis

When was your third child with hearing loss diagnosed?

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Year

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Types of Technology

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Hearing Aids

Cochlear Implants

BAHA

ABI

FM/Remote microphone

LSL Services

I currently receive services from a Listening and Spoken Language Specialist.

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Date of Hearing Loss Diagnosis

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Date of Hearing Loss Diagnosis

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