Date of Referral:
Date of Birth:
Current Grade/Placement:
Student Name:
Contact Telephone Number:
School District:
School District Contact (name and title):
District Mailing Address:
Service(s) requested:
Ongoing mainstream support services for student and staff
In-service education for staff
Initial consultation with mainstream educational consultant to determine services needed
Initial consultation with mainstream education consultant and educational audiologist to determine services needed
Consultation with educational audiologist focused on developing a favorable auditory environment for learning
Consultation and evaluation by a speech language pathologist focused on impact of the student's hearing loss on language and speech development
Consultation with a psychologist or social worker who specializes in the psychosocial needs of hearing impaired learners
Comments:
Attach information about the student's hearing loss including audiological reports, type of amplification and/or assistive technology used. We welcome your calls and will be happy to respond to any questions you might have.
Mail or FAX referral form to:
Mainstream Resource Services Center
Lake Drive Program, 10 Lake Drive
Mountain Lakes, New Jersey 07046
Phone: 973-299-0166 Fax: 973-299-9405
Email Us
10 Lake Drive. Mountain Lakes, NJ 07046 973-299-0166
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