Refer a Family

To Professionals Serving Deaf and Hard of Children in California

California Hands & Voices is honored to have a positive environment for meaningful Parent-Professional Collaboration throughout the state. Our professional allies and board members have been and will continue to be instrumental in helping our organization grow by referring families for support. Parent-Professional Collaboration is a high value and part of our mission at Hands & Voices. If you share this goal, we invite you to contact us to start the conversation. You can also visit the Meet our Team page to contact the area rep that serves your region. We’d love to know how we can support you and the families you work with. We look forward to talking to you today!

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Family Referral Form

We can use your help in identifying families who could benefit from connecting to another parent.

If you know of a family who would value a connection, please refer them to us through this form, after gaining permission from the parent.

Referral Source

Referring Individual/Organization *

Role of Referring IndividualSelect from list…Self ReferralAnother ParentAudiologistENTHands & VoicesHearing Coordination Center (HCC)Early Start (0-3 years old)School District (3+ years old)LEAD-K Family ServicesParent CenterRegional CenterFamily Resource CenterOther

Phone *

Email *

Family Contact Information

Parent's Full Name *

Phone *

Email *

County *Select County…AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaOut of State

Primary Language of Parent *EnglishSpanishASLOther

You may select multiple languages

EthnicityChoose from list…African American / BlackAsianHispanic / Latino;Native Hawaiian / Pacific IslanderNon-WhiteWhiteUnknown / Decline

This information is helpful for grant writing, but purely optional

Reason for Referral

Family Interested InChoose one topic…AdvocacyAuditory NeuropathyAmerican Sign LanguageAtresiaAuditory ProcessingBilingual Education / CSDCollege / VRConnexin 26/30Cued SpeechDeaf BlindEarly StartEventsHearing Tests/AudiogramIDEAIEP/IFSPListening Spoken Language / SchoolsLocal Deaf AgencyMeeting a DHH AdultMental HealthMinimal Hearing LossMondiniMultiple DisabilitiesOnline Social GroupsOT/PTOther (see Other Info box)Parent Links / Meet local familiesResearch (contact family)Signing Exact EnglishState/National OganizationsTechnologyTotal CommunicationTransition

Select the topic that the family is MOST interested in. Enter any other topics in the Additional Information field

Additional Information *

Signature and Date

Your signature below confirms that you have permission from the parent to make this referral

Signature of Referring Individual *

Clear Signature

Date of Referral *

Submit Referral