Interpreter Request Form

Requester Contact Information

Business/Organization Name (PLEASE USE LEGAL NAME OF BUSINESS)

Requestor First Name:

Requestor Last Name:

Requestor Phone Number:

Email Address:

FAX Number (If Applicable):

Deaf Client Information

Deaf Client Name

Deaf Client Date of Birth:

Client Interpreter Gender Preference:

Request Details

Assignment Type:

Type of Interpreters requested:

American Sign Language InterpreterCART (Captioning Services)Certified Deaf InterpreterSpecialized Interpreter (Tactile, Trilingual) Check more than one if requesting different types of interpreters

PO Number (If Applicable):

Doctor's Name (Optional but preferred):

Case Number:

Name of Judge:

Hearing Type/Reason:

What Kind of Specialized Interpreting are you needing?

In Person or Virtual?

VirtualIn Person

If In-Person interpreting services are unavailable, would you be open to Virtual interpreting?

YesNo

Appointment Details

Date of Appointment

Start Time:

Estimated Duration Of Appointment (In Hours)

If there is more than 1 date being requested, please list dates and times below.

Detailed Description of Appointment:

What Kind of appointment will be taking place? Examples could be: A Visit to the ER for broken foot, or; Legal Hearing for traffic violation. (PLEASE DO NOT WRITE ASL SERVICES IN THIS BOX)

Link for Meeting (If None provided, we can provide a link)

Location Name:

Location Of Assignment- Street Address

Building/Suite (If Applicable)

City

State

Zip code

Point of Contact Name

Point of Contact Phone:

Special Meeting Instructions/ Notes not previously listed:

File Upload (If Needed)

For agendas, map of buildings, or extra information you want to share with interpreters. (you can also email them to us at scheduling@dacinterpreting.com)

Questions, Comments, Concerns? Contact us here:

Phone: (214) 521-0407

Email: scheduling@dacinterpreting.com
For after hours requests, call 469-236-5868. Any cancellations or communication during after hours also need to be directed to our After Hour Coordinator at 469-236-5868 or at urgent@dacinterpreting.com.

Contact Information