Child Intake Form

Thank you for your interest in services at the Listen Foundation. This form helps us understand your child’s hearing history, current services, and communication needs so we can schedule an appointment with the most appropriate therapist.

Please complete the form as thoroughly as possible. Some questions may not apply to your child, and it is okay to leave those blank. A member of our team will follow up if additional information is needed.

Privacy Notice
Information submitted through this form is used solely for internal clinical coordination. Access is limited to authorized Listen Foundation staff and your assigned therapist. The Listen Foundation follows HIPAA guidelines to protect personal health information and does not share information without written consent. No other uses beyond internal care coordination.

Today's Date(Required)

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Ethnicity

Primary Language(s) Spoken at Home(Required)

Parent/Guardian Name(s)(Required)

First Last

Parent Name 2

First Last

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(s)(Required)

Email Address(Required)

Enter Email Confirm Email

Diagnosis (if known)

Degree of Hearing Loss - Right Ear

Degree of Hearing Loss - Left Ear

Date Hearing Loss was Identified

Hearing Technology Used (manufacturer and device name) or Enter "None"(Required)

Referring Provider (Name, practice, and email/phone)

Managing Audiologist (Name, practice, and email/phone)

Ear, Nose, and Throat Professional (Name, practice, and email/phone)

Early Intervention or School Provider (Name, practice, and email/phone)

Select if Your Child has the Following:

Individualized Family Service Plan (IFSP)

Individualized Education Program (IEP)

Assigned Listen Therapist (if known)

Preferred Session Type (select one)

In-Person

Tele-Health

No Preference

Date Funding Application was Sent (if applicable)

Your Goals for Your Child's Communication

Additional Information You Would Like Us to Know

There have been many times when she has announced how thankful she is that she can hear and speak. She truly appreciates the gift.

–Becky, Mother of a Listen Graduate

Help Make a Difference!

Help us fulfill our mission of getting more Colorado children listening and talking. Your contribution is used primarily to fund Listening and Spoken Language Therapy from our amazing network of therapists, helping children desperatly in need across the state.

The Listen Foundation
6950 E. Belleview Ave
Greenwood Village, CO, USA 80111

info@listenfoundation.org
(303)-781-9440

Fifty Years of Impact and Looking Ahead

As we reflect on 2025, I’m incredibly grateful for the families, supporters, and community who make the work of the Listen Foundation possible. For more than 50 years, Listen has supported children who are deaf or hard of hearing across Colorado, helping them develop...

Colorado Gives Day Idea

From Todd Hallberg, Executive Director: Since stepping into this role, I have been truly humbled by the incredible support for the Listen Foundation from so many of you. At the same time, it’s difficult to hear that many Colorado families with babies who are deaf or...

2025 Fundraising Luncheon Announced

The Listen Foundation 2025 Fundraising Luncheon will be on Sunday, October 5th from 11:30 a.m. to 1:30 p.m. Join the Listen Foundation at our annual free luncheon to celebrate the children who have learned to listen and talk, allowing them to experience life just like...

The 2025 Non-Event is Here! Since 1994, the Listen Foundation has hosted its annual Non-Event. A unique fundraising campaign that’s beloved for its simplicity. No formal attire, no babysitters, no banquets, just an opportunity to make a meaningful difference from the...

Message from New Executive Director Todd Hallberg

I’m honored and excited to step into the role of Executive Director at the Listen Foundation. This organization holds a very special place in my heart—my son, Derian, is a proud graduate of the Listening and Spoken Language (LSL) therapy program. Our family’s journey...

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