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University Translators Services, LLC
ORAL INTERPRETER REQUEST FORM
EMAIL REQUEST TO: REQUEST@UNIVTRANS.COM
ONLINE FORM WEBSITE: http://univtrans.com/interpreter-request-form/
Requested By: Waleed Vaid
 Submission Date (Today's Date):
 03/20/2023
 Name (Your name):
 Waleed Vaid
Company / Organization Name:
Washtenaw County CMH Access
 Phone number / Fax number::
 734 544 3050
 Email Address:
 vaidw@washtenaw.org
 Date & Time of Service: 3/28/2023 3 PM
SERVICE DATE (please include day of week in writing): 3/28/2023 3 PM - Tuesday
MO TU WE TH F SA SU (please also circle the day of the week)
Start Time: (write start time below)
3:00
End Time: 4:30
Please indicate how many hours you want to reserve? 1.5 hours
 Request Information: 
 Language/Country of Origin or ASL or CART: 
 Spanish
Name of the Limited English Proficient (LEP) Person(s) and include title (e.g. parent, defendant, patient, witness, juvenile, suspect, etc.)
Client: Reynoso, Juliett
Mom: Yepez, Erika

Subject (e.g. evaluation, divorce, domestic, etc.):
Mental Health Services – Youth & Family
Type of Appointment (e.g. IEP, prelim hearing, pretrial, medical apt. sentencing): 
Eligibility Assessment
Case /Patient/Consumer Number
Date of Birth (if applicable): 
1206482, DOB: 03/04/2014 
Other Participants Names/Titles (e.g. Attorneys, Prosecutors, Witnesses, etc.):
Mental Health Professional: Dawn C. Leimstoll

Please add or attach pages that include any other information related to your request; the more informed your interpreter is the better! 
 REMOTE VIDEO INTERPRETING (RVI) (e.g. Zoom, GoogleMeet etc.) OR × ON-SITE
Company / Organization Name
Washtenaw County CMH
Address / City / State / Zip
2140 E. Ellsworth Rd., Ann Arbor, MI 48108
Remote Link, Meeting ID, Password
n/a
 Meeting Contact Person
 Dawn C. Leimstoll
 Meeting Contact Person Cell Phone
 Cell: 734.368.5977, Front Desk: (734) 222-6869
 Billing Information (Where and to whom should we send the invoice?):
Organization Legal Name for Billing
CMH
Address / City / State / Zip
555 Towner St., Ypsilanti, MI 48197
Name of Billing Contact
Sally O’Neal
Phone number: / Fax number:
734-544-6807
Billing Contact Email Address:
amoss@washtenaw.org