Request for ASL Interpreting Services

Which Office: BridgesTN (Middle Tennessee), BridgesWEST (Mid-South) or BridgesEAST

Please note that BridgeesDHH provides services throughout Tennessee and surrounding states. The designations above reference the physical offices from which interpreters work.

Requester Name

First NameLast Name

Company/Business/Organization

Requester Phone*

Area CodePhone Number

Requester Email*

example@example.com

Confirm Requester Email*

example@example.com

Requester Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you used our services before?*

Billing Contact*

First NameLast Name

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Bill information is mandatory unless this box is checked, indicating that invoices can be sent to the requester.

PO or Routing Code Number

Can the invoice be emailed?*

Type of Services Requested*

Service Context*

Name of Deaf Client*

First NameLast Name

DOB/MR#

Date of Appointment*

Date

Start Time Interpreter Needed*

:HourMinutesAM/PM Option

End Time Interpreter Needed*

:HourMinutesAM/PM Option

Timezone

Name of Medical Provider Patient is Seeing

First NameLast Name

What Will Patient Be Seen For?

Will Appt Require a Male or Female Interpreter?

Service Location*

Name of medical practice, school, court or other location where services will be provided.

Exact Address of Appointment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parking | Driving Instructions*

On-Site Contact*

First NameLast Name

On-Site Contact Number*

Area CodePhone Number

Please List ALL Individuals to be Present at Appointment and their Roles*

If Requested, Name of Preferred Interpreter

Briefly describe the setting and what will be taking placewhen the interpreter arrives so that the interpreter may prepare for theassignment.

Is there anything else we need to know?*

dress requirements, event to be videotaped, etc., agenda or program

Please click here to review our policies.

Our current rate sheets are available by request. Please contact interpreting@bridgesfordeafandhh.org.

Please click here and sign below to acknowledge you have reviewed and agreed to our policies. We cannot proceed with services without this acknowledgement. Please note that our policies include a cancellation/rescheduling policy because we are reserving and guaranteeing payment for the service provider's time. This policy applies regardless of whether the Consumer or Request cancels the job.*

click here

By signing below, you specifically acknowledge an understanding that all requests carry a 48-business hour cancellation policy. Any requests cancelled within 48-business hours of the start time of the request will be invoiced for services.*

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Date*

Date