Sensory Impairment Services Intake
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Non-binary
Prefer not to say
Phone
Email
Address
Contact Person (if applicable)
Contact Name
Relationship
Contact Phone
Sensory Impairment Details
Type of Impairment
Visual
Hearing
Dual
Other
Description / Diagnosis
Date of Onset / Diagnosis
Current Supports and Services
Support Services Currently Receiving
Assistive Devices Used
Goals and Needs
Client Goals / Desired Outcomes
Support Needs or Accommodations
Additional Information