Hearing & Speech Center
500 South Laspina Street
Tulare, CA 93274
(559) 685-2626
email:
jimb@tcoe.org
Audiology Referral
*
required fields
Name of Student:
*
Date of Birth:
*
Parent/Guardian:
*
Address:
*
City:
*
Zip:
*
Phone:
*
School:
*
Grade:
*
Teacher First Name:
*
Teacher Last Name:
*
Teacher E-Mail:
*
Special Education Services:
Name of Service Provider:
Referred by:
*
E-Mail:
*
A carbon copy of this completed form will be e-mailed to this address upon submission.
Location:
(if different from school above)
Phone:
*
Reason for Referral:
*
Contributing Medical History:
Ask parents to wait a couple of days (to allow for receipt and review of referral), then call Linda Corral at (559) 528-6925 for an appointment. The referring individual will be notified via e-mail of the appointment date and time. The referral will be discarded after 30 days if parent/guardian has not called for an appointment.
NOTE:
A copy of this referral will be e-mailed to the address listed in the Referred By E-Mail field above.
Map to the Hearing & Speech Center
in Tulare
(pdf file)
This map requires Adobe Acrobat Reader to view and print. You may download the freeware version at the
Adobe website
.
If you have any questions or concerns regarding this referral, please contact:
James A. Beauchamp, Au.D.
e-mail:
jimb@tcoe.org
phone: (559) 685-2626
