Telepractice Request Form

Thanks for your interest in Telepractice with JTC for Auditory Verbal Therapy. Please provide this information about your child. This will help staff determine what might be offered. Someone will check back with you about availability and eligibility.

Must reside in CA or outside the U.S.

Family primary communication:

Amount of Hearing Loss:


Device Left:
Device Right:

What is child(s) main way of communicating?
Is child attending school?

Child receiving services for (check all that apply):
Language Professionals working with child (check all that apply):

Prior participation in JTC services?

Availability is limited but your request will be reviewed soon and you will receive a response in a few days. Thank you.

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