Help the Florida & Virgin Islands (FAVI) Deaf-Blind Collaborative to help children and youth with deaf-blindness and their families!
Family Intake Survey
The FAVI Deaf-Blind Collaborative encourages families to report their child / young adult
(birth through age 21) with multiple disabilities that include
diagnosed or suspected hearing and vision loss using the online Family Intake survey
(available in English and Spanish).
Request individualized assistance for your family and / or your child’s educational team
using the online Family Intake survey
Educators and professionals should also make referrals using the Family Intake survey,
but consent must be provided by a parent/guardian for exchange of information and records.
Consent for Exchange of Information & Records
Parent(s) / Guardian(s) must provide consent for the exchange of information and records before child-centered consultation with educators and professionals may occur. The family will indicate which individuals and organizations may exchange information and what types / formats of information may be shared.
Once a family has provided consent, any authorized family member or team member may make a request for Technical Assistance (training, consultation, individualized support) from
or participate in child-centered consultation with the FAVI Deaf-Blind Collaborative.
- Consent for the Exchange of Information & Records
- Consentimiento para el intercambio de información _ registros
Reporting by mail or fax:
PLEASE SUBMIT ALL FORMS WITH ANY IDENTIFYING INFORMATION
(names, addresses, birth dates, etc.)
- BY FAX 352-273-8539 OR Contact Shelly Voelker (firstname.lastname@example.org)
for mailing instructions. Email is not a HIPAA-compliant means
of exchanging protected information.
- Download a Family Intake Form for families reporting their child with deaf-blindness
- Download a Child Count Reporting Form
for educators and professionalsreporting a child / young adult with deaf-blindness
(combined hearing and vision losses-dual sensory impaired) to the deaf-blind registry
- Download a Consent for Exchange of Information and Records