Refer a ChildRefer a Child to Telethon Speech & HearingYour Name*Name of your Clinic / Practice / School / Kindy*Your email* Section BreakYour phone number*Client's name*Client's age*Please enter a number from 0 to 100.Clients email* Client phone number*Section BreakReason for referral Potential language delay Hard to understand speech Difficulty following instructions Stutter Social communication Literacy skills Other Ringing in the Ear Dizziness and Vertigo Hearing Loss Blocked Ears Discharge Difficulty Hearing in Noise Foreign Objects in the EarPlease select all that may applyReason for referral - further information*Has the client been informed of the referral?*YesNoCAPTCHAReason for referral*Potential language delayHard to understand speechDifficulty following instructionsStutterSocial communicationLiteracy skillsCombination / OtherCommentsThis field is for validation purposes and should be left unchanged.Refer a ChildHearing Loss in ChildrenHearing Services for Newborn BabyHearing Services for Pre-School ChildrenHearing Services for School-Aged ChildrenEarly Intervention Hearing Impaired Program (Chatterbox)
