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De-identifying Referral Form

De-Identifying Referral Form

Project Reach logo; serving youth who are deaf-blind, their families, and their schools

If you have any difficulties with this form, please email Michelle Clyne.

Please click Submit at the end of this form.

Submitter's Information

   

 

Child's Information

Some information is required, only enough so that a unique count to the National Deaf-Blind Child Count can be made. The individual child will NOT be identified, and the child’s family is not being made eligible for Project Reach services. Project Reach services CAN be accessed through the "Referral for Eligibility" process at any time the family wishes.

Directions: Use the first two initials of the first name, and the first two initials of the last name. For example, Mary Smith would be MASM.

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