Submit a Referral

Please complete the form below to submit a referral to the Kentucky Deaf-Blind Project. We will be in touch soon to assist with the referral.

The first seven questions are required, but we encourage you to provide as much additional information as possible. The more we know, the better we can help the child.

You may also download a printable version of the referral form and return to:

Kentucky Deaf-Blind Project
229 Taylor Education Building
Lexington, KY 40506

Referrals can be emailed to kim.zeigler@nulluky.edu or faxed to (859) 257-1325.


Referral Form

Today's Date:
Child/Student Name:
Child's Birthdate:
Is the parent/guardian aware of contact being made with the Deaf-Blind Project?
Parent or Guardian's Name & Address:
Parent's Phone Number:
Parent's Email:
Referrer's Name:
Referrer's Title/Role:
Referrer's Email:
Referrer's Phone:
School or Agency Name & Address:
Teacher/Interventionist:
Program Type (ex. Early Childhood, FMD, Homebound, etc.)
Etiology:
Does the child have a vision impairment or challenge?
Does the child have a hearing impairment or challenge?
Physician Name(s):
Other Relevant Information or Comments: