Help the Florida & Virgin Islands (FAVI) DeafBlind Collaborative to help children and youth with deafblindness and their families!
Family Intake Survey
The FAVI DeafBlind 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).
Before requesting individualized assistance for your family and / or your child’s educational team,
use the online Family Intake survey to report the student to the Florida DeafBlind Registry.
Educators and professionals should also begin referrals by using the Family Intake survey,
but consent must be provided by a parent/guardian for exchange of information and records.
Once a child / young adult has been added to the Florida DeafBlind Registry, the family or educational team may make a Request for Technical Assistance from the FAVI DeafBlind Collaborative.
Educators who are simply reporting a student to the Florida DeafBlind Child Count (“census”), as required by Florida statute, should use the DeafBlind Child Count page.
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 DeafBlind 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 (shellyv@ufl.edu)
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 professionals reporting a child / young adult with deafblindness
(combined hearing and vision losses-dual sensory impaired) to the deafblind registry - Download a Consent for Exchange of Information and Records