ELIGIBILITY FORM FOR INFANT HEARING PROGRAM

Eligibility Form for Infant Hearing Program 
Infant Hearing Screening and Audiology Services

One of the criteria below must be indicated for IHP services:
You live in Toronto
Your child is between zero to six years old
Your child has permanent hearing loss

If your child does not meet eligibility criteria, please contact your child’s doctor for a referral or visit College of Audiologists and Speech-Language Pathologists of Ontario to find an audiologist. You will want to ensure that the audiologist has experience working with young children.

Referral Source Information
Date:
/
/
Please enter a valid date
Name:
Last Name, First Name
This question is required
Last Name, First Name
Phone Number 
This question is required


Client Information
First Name:
This question is required
Last Name:
This question is required
DOB:
This question is required
Sex
Select...
This question is required
Gestational Age (# weeks pregnant):
This question is required
Corrected Age (Current Age - # Weeks Premature (using 37
weeks as full-term) :
This question is required
Address (Apt#-Street #/Street Name/City/Province/Postal Code):
This question is required
Parent/Legal Guardian Name 1:
This question is required
Phone Number:
This question is required
Email:
Please enter a valid email
Parent/Legal Guardian Name 2:
Phone Number:
Email:
Please enter a valid email
Interpreter Needed:
Yes
No
Language Spoken:

One of the following criteria must be met to be eligible for the Infant Hearing Program service

INFANT HEARING SCREENING- UNDER 2 MONTHS CORRECTED AGE
Missed Universal Newborn Hearing Screening (UNHS)
Passed UNHS and physician is concerned about change in hearing status
This question is required

IHP AUDIOLOGY SERVICES- INFANT 2-24 MONTHS CORRECTED AGE
Post-natal infection associated with a permanent hearing loss (PHL) including meningitis, viral encephalitis or labyrinthitis.
Extracorporeal Membrane Oxygenation (ECMO)
Significant head trauma associated with loss of consciousness or skull fracture
This question is required
Diagnosis of one or more of the following:
Alport Syndrome
Pendred/Enlarged Vestibular Aqueduct
Branchio-Oto-Renal (BOR)/Branchio-Otic (BO)
Proven cCMV
CHARGE Syndrome
Stickler Syndrome
Craniofacial anomaly (cleft palate, atresia/ microtia)
TORCHES
Crouzon Syndrome
Treacher-Collins Syndrome
Down Syndrome
Usher Syndrome
Goldenhar (OAVS) Syndrome
Waardenburg Syndrome
Neurofibromatosis II (NF2)
Hyperbilirubinemia - Exchange Criterion

IHP AUDIOLOGY SERVICES- CHILD 2-6 YEARS OF AGE
Proven cCMV
Proven Meningitis
PHL Diagnosis (A description of the hearing loss must be provided below):
This question is required
Please describe hearing loss and any additional related needs
This question is required


Consent
Are Parents/Legal Guardians aware of and consenting to this referral?
Yes
No
Please choose an answer
Any special custody arrangements? CAS and/or adoptive arrangements?
Yes
No
Please choose an answer
24 questions to go

Personal health information contained on this form is collected in accordance with the Personal Health Information Protection Act (2004) for the purposes of providing the Infant Hearing Program. The information captured on this form will be entered into a secure database administered by the Ministry of Children, Community and Social Services. Access to your baby's record is protected by Surrey Place. If you have any questions regarding your consent or our services, please email infanthearing@surreyplace.ca