CRITERIA  
APPLY
PRESS
LATEST RECIPIENT


The purpose of these questions is to enable you to provide some initial information which will determine whether the candidate is suitable to proceed to the next phase of this process.

It is important that you answer all questions honestly. There may be some information you do not yet have – please be honest about this to enable us to fairly evaluate where you are in the process, and what steps still need to be taken in your case.
1. REFERRAL
Please give us the details of the person who referred you to the Trust, including their name and contact details:
 
2. PROOF OF CONSULTATION WITH ENT/SPECIALIST
Please give us the details of the doctor that you have seen.
 
    Do you have supporting documentation from this Doctor?
3. PROOF OF ALL AUDIOLOGICAL ASSESSMENTS
To be considered we will need details of all the audilogical tests and assessments that have been done.
    Do you have supporting documentation for all the audiological assessments?
4. HEARING AID TRIAL
We will need proof from you that you have had a hearing aid trial for at least 6 months.
    Do you have supporting documentation of at least 6 months of hearing aid trial?
    Please fax a copy of your audiogram to (011) 642 4275 - attention "Hear for Life"
5. COUNSELLING
In the box below, please give us the details of any counselling in this regard (family counselling, child counselling, learning assessment of child), and by whom the counselling was done.
 
    Do you have supporting documentation for this counselling?
     Is the applicant currently using hearing aids?
6. RECOMMENDATION
    Have you been recommended for a Cochlea Implant?
If you have been recommended for a Cochlea implant, please give us the name and contact details of the person who recommended this.
 
    Do you have supporting documentation?
7. SOCIOLOGICAL NEEDS ANALYSIS

An in-depth sociological needs analysis will be done before any funds are committed. The following details will be needed:
Age
Assesment to make sure child/adult can be cared for emotionally
Proof of financial ability to afford batteries and other associated costs
Proof of financial ability to afford ongoing therapy and teaching of cochlea recipient
Assesment of child/adult environment
Medical Aid details
Proof of income

    Do you have supporting documentation for all of the above?
    Where is the child currently at school?
Name of contact person at the school
Contact details
   Is the applicant currently receiving speech therapy?
Name of therapist
Therapist's contact details
   Do you have medical aid?
Once all 7 of these steps have been followed the potential recipient will be put forward to the Trust for consideration. It is important to note that the Trust only pays for the actual cost of the cochlea unit and does not pay for any associated costs of the programme.
  Contact Details
Contact person
Contact number
Alternative contact number
Email address
Where do you live?
Name of potential cochlea recipient
Date of birth
Relation to the recipient (write 'self' if it is for you)
 
 
© 2006 Hear for Life
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