Consultation FormWelcome! Please fill out the questionnaire below to provide more details. Contact Information Name * First Name Last Name Preferred Pronouns They Them Theirs He Him His She Her Hers Other Email * Text / VP * (###) ### #### Preferred Method of Contact * Preferred Language of Delivery * District/Agency Name * Role * About your DDBDDHH Program Briefly describe your current DHH program. * (e.g., number of students, settings served, staffing, strengths and challenges) What populations do you primarily serve? * (check all that apply) Deaf only (residential school) Deaf is inclusive term for all, including those with additional disabilities (DDBDDHH) Early intervention 0-3 K-12 mainstream only Entire spectrum of DDBDDHH (0-24 y/o) Other How many DDBDDHH students are currently served in your district? * (open-ended or use ranges) What services do your students currently receive? ASL or bilingual instruction Interpreting services Deaf interpreters Audiology services Speech/language Itinerant support Signing aides Deaf adult role models, coaches Other Leadership & Capacity What is your current role within your program? What responsibilities do you have related to leadership, supervision, or decision-making? * What are your goals as a leader in this program over the next year and beyond? * Other than you, who are the key decision-makers or influencers for DHH programming in your district? Would they be involved in this leadership support? * Needs & Areas of Growth What are the biggest challenges currently facing your DHH program? * What professional learning topics are most urgent for your team? * (check all that apply) IEP/504/Triennial Processes Creating Language-Rich Environments Deaf Cultural Competence Supporting DDBDDHH Students with Diverse Learning Needs Behavior and Mental Health Supports Family Engagement Interpreters DCCW (Deaf Community Cultural Wealth) + Deaf Adults in the Classroom Other Have you previously worked with an outside consultant or coach to support your DHH program? * Yes No If yes, what support was provided? Commitment & Readiness Why are you interested in the Leadership Cohort? What do you hope to gain? * Are you able to commit to the full 8-month program (individual sessions, group sessions, recorded content)? * Yes No Maybe Will you have dedicated time during your workweek to engage with the cohort activities and materials? * Yes No Uncertain Will your participation be supported by your district or supervisor? * Yes No In process Other Is there anything else you’d like me to know about you or your program? Thank you!
