Dedicated to helping Deaf and hard-of-hearing children grow and learn in a world they cannot hear
Home Intervention for Deaf Children

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To enrol a child in the HI HOPES programme, please complete the referral form below:

Referral Agent Name:
If 'other', please specify
Are you
If 'other', please specify
Child & family details:  
Child's name:
Date of birth:
Home language:
Contact details : Please fill in at least two different contact numbers
Mother phone:
Mother alt. phone:
Father phone:
Father alt. phone:
Grandparents phone:
Grandparents alt. phone:
Physical address:
Date of diagnosis:
Type of hearing loss:
Is the hearing loss:
Do you have a copy of the audiogram?
If 'yes', please email to or fax to 011 717 3750
Are there other concerns, apart from hearing loss?
If 'yes', please specify

Deaf boy



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