The Ohio Brain Injury Connection Referral Form

Navigating life after a acquired brain injury can be complicated enough. We are here to offer support and help. The Ohio Brain Injury Connection is a free resource facilitation service for all Ohioans and/or their loved ones who have experienced an acquired brain injury.

We use a person-centered approach as our Resource Advisor will work with you to develop a personalized plan for advocacy and support. There is no fee for participating with one of our resource advisors. We do not replace medical care but offer resources and help with care management.

Please note: an acquired brain injury is any brain injury that happened after birth such as a traumatic brain injury, an anoxic brain injury caused by drowning or suffocating, a stroke, etc.

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* 1. By filling out this form, I confirm that I or the individual provides permission on this form to be contacted by the staff at the Ohio Brain Injury Connection

Yes, I provide permission to be contacted by the Ohio Brain Injury Connection.

Yes, I have been given consent or am the proxy of the individual on the form and this individual has provided consent to share their contact information.

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* 2. Contact Information for the individual we will reach out to to provide support.

Name

City/Town

State/Province

Email Address

Phone Number

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* 3. Cause of Injury (Example traumatic brain injury, stroke, anoxic brain injury, brain tumor)

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* 4. I am seeking services for....

Myself

I am a caregiver for an individual who has experienced brain injury.

I am a professional such as a social worker, discharge planner, health care/rehabilitation professional referring an individual.

Other

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* 5. Please provide a few sentences on how our resources advisor's can begin to help. (Example: looking for help with memory, looking for support groups for brain injury, looking for help filling out forms)