Hearing Aid Clinic Request Form

Free Hearing Clinic at CBFL’s Adaptive Living Solutions Expo

CBFL is offering free hearing assessments at the Adaptive Living Solutions Expo. If you have been struggling with hearing, this will give you a chance to secure hearing aids at little or no cost to you. If a hearing aid is recommended by the audiologist, you may qualify for hearing aids, with costs determined on a sliding scale based on income. Our coordinators will review your eligibility and discuss the details with in person.

Pre-registration is required to participate.

CBFL Core Coordinator will verify your information and assist you with completing the intake and let you know what documents you must submit. Once recieved, you’ll receive an appointment time.

Spaces are limited and available on a first-come, first-served basis. Secure your spot today!




Patient Information















Medical/Audiologic History


Medical History





Hearing Difficulty in Various Environments

Please check the box that BEST applies to you.

Listening Situations









Almost done. Where should we send the confirmation?

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