Family Referral Information and Directions
Thank you for your interest in referring families of newly diagnosed infants and toddlers to the HoPE Parent Partnership Program℠. In order for the Program to provide outreach services to a family, a complete referral packet must be on file. A complete referral packet includes:
• HoPE Parent Partnership Program℠ Parental Consent Form – signed and dated by the parent/guardian
• HoPE Parent Partnership Program℠ Family Referral Form – completed by the referring audiologist
• Most recent hearing screening or diagnostic audiology evaluation
Making a Referral to the Program
Please follow the steps below to ensure a smooth referral process for families. Making a referral is an easy 3 step process:
1. Please have parent or legal guardian sign the HoPE Parent Partnership Program Parental Consent Form (download here)
2. Please complete the online HoPE Parent Partnership Program Family Referral Form HERE. To download the PDF version, CLICK HERE. To assist in completing the PDF referral form we’ve included a complete list of ECI Programs for 2011 – 2012. Please CLICK HERE to download the list.
3. If you are submitting the HoPE Parent Partnership Program Family Referral Form electronically through the link above, please scan and email the signed consent with hearing screening or diagnostic audiology information to email@example.com or you may fax the documents to 214-501-3478.
If you cannot scan or email these documents please mail them to:
HoPE Parent Partnership Program
c/o Shayne Brown, Coordinator
PO Box 1527
Wylie, TX 75098
Thank you for your referral! The HoPE Parent Partnership Program Coordinator will provide your office with an email or fax-back confirmation of the receipt of the referral within 24 hours. The HoPE Parent Partnership Program Coordinator will contact the family within 48 hours of receipt of a complete referral packet.
If you are a parent interested in referring your family to the HoPE Parent Partnership Program℠ please complete the online referral form or you may download the PDF version and submit your family’s referral through email or fax. You may also contact Shayne Brown, Program Coordinator, directly at 817-771-1170 to make a self-referral to the program.
Parent/Family Self-Referral Form
You may also download the Parent/Family Self-Referral Form HERE
Please email the completed form to Shayne.firstname.lastname@example.org or you may fax the completed form to 214-501-3478.
Thank you for your interest in the HoPE Parent Partnership Program℠!
HoPE Parent Partnership Program℠ Informational Webinar
If you are interested in learning more about the HoPE Parent Partnership Program℠, including how to make a provider referral on behalf of families you are serving, we invite you to view the informational webinar for more information. The webinar was designed to address outpatient hearing screeners and/or diagnostic audiology providers, but the content is relevant and applicable to all EHDI providers interested in partnering with the program.
If you are a parent of a child with suspected or diagnosed hearing loss, you are welcome to view the webinar as well to learn how the HoPE Parent Partnership Program℠ is able to support you and your family in the early days, weeks, and months of learning about your child’s diagnosis.
REGISTER HERE for the EHDI Provider Informational Webinar