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NCIP Cochlear Implant Referral Form for Children
(18 years and under):

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To ensure your referral is accepted and actioned immediately, it is vital that we receive the complete information requested (referral document and check list).  If you are not an audiologist fill in the form as best you can.

 

The referral will not be processed until we have all essential information so getting the name of your client’s audiologist will make the process faster.

 

If your client does not meet referral criteria we are happy to arrange a private assessment on receipt of this form. 

Referrer Details

Client Details

Have they been referred to an AoDC?
Please ensure you have
Enclosed copies of your clients
Please upload documents here or email them to childci@hearinghouse.co.nz
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For all clients up until their 19th birthday. Children are eligible for two cochlear implants under the public programme.

 

Public Referrals 

 

Audiological guidelines:  

  • Children who have a bilateral severe hearing loss or worse, from 1 kHz to 8 kHz in the better ear on ABR testing, or on a reliable unaided pure tone audiogram. 

  • Children with limited aided speech information above 2 kHz (as seen on speech-mapping). 

  • Children with a severe reverse sloping hearing loss or worse, whose speech and language are not progressing adequately.

Special cases:

Meningitis

Children who have recently suffered from meningitis which has caused a bilateral or unilateral sensorineural hearing loss >65dBHL, should be urgently referred following diagnosis. 

Auditory Neuropathy Spectrum Disorder (ANSD)

Children with a confirmed diagnosis of ANSD and who are not progressing in their speech and language development. Referrals are considered irrespective of PTA. Children with additional needs who also meet the audiological criteria will be accepted for assessment.  

Private Referrals

 

Audiological criteria:

 

Single Sided Deafness (SSD)

Asymmetric hearing loss (where the worse ear has a severe hearing loss or worse, from 1 kHz to 8 kHz).

 

Other:

  

If you are not a New Zealand citizen or do not hold a residency class visa we can do a private assessment for cochlear implantation. Referrals are accepted at any age. 

If you are in doubt about a possible referral, please refer or call our Paediatric team to discuss. 

Tel: 09 579 2333 or 0800 254 783

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Thank you for your referral.

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