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Please take a moment to fill out the form below:
* Required Fields

Name:
Address:
City:
State:
Zipcode:
Home Phone:
Other Phone:
Social Security No:
Date of Birth:
Gender:
Date of Injury:
Cause of Brain Injury:
Due to:

Do you (client) have:
A history of substance and / or alcohol abuse:	Yes No
A history of mental illness:	Yes No
A history of aggressive behavior / violent outbursts:	Yes No
If yes, please comment:

Do any of the following apply to you (client)? (Check all that apply.)
Difficulty maintaining attention and concentration:
Difficulty planning, scheduling and organizing:
Difficulty with reasoning and problem solving:
Impaired perceptual skills:
Impaired reading and writing skills:
Impaired verbal communication:
Impaired judgment and / or intuition deficits:
Long-term memory problems:
Short-term memory loss:
Slowness of thinking:
Other disabilities or difficulties:

Please rate your (client’s) functional abilities using the following scale: 5 = Totally independent / No difficulty 4 = Needs supervision / Some difficulty 3 = Needs assistance and supervision / Moderate difficulty 2 = Needs significant assistance / Severe difficulty 1 = Totally dependent / Unable
Financial management:
Homemaking (such as laundry, shopping, cooking):
Speech and Language:
Learning:
Mobility:
Self-care (bathing, grooming, dressing, feeding, etc.):

Do you (client) use any of the following? (Check all that apply.):
Equipment for bathing / showering:
Hearing aid:
Communication device:
Computer (for communication):
Cane:
Walker:
Wheelchair:
Power chair:
Other:

Please check services that you (client) needs:
Brain injury education:
Case management:
Cognitive / problem solving:
Equipment procurement:
Financial management:
Housing:
Life Skills Training:
Medical referral:
Medication management:
Mental health referral:
Recreation / leisure:
School:
Social:
Vocational:
Transportation:
Other services you (client) may need that are not listed above:

Please check any other community services that you (client) may be receiving:
Community Services Board (CSB) / Mental Health Services:
Department of Rehabilitative Services (DRS):
Homeless shelter services:
Veterans Affairs services:
Medicaid Waiver services:
Other services not listed above:

What type of insurance do you (client) have?

From which sources do you (client) receive income?
Social Security Income (SSI):
Social Security Disability Income (SSDI):
Employment wages:
Settlement / trust:
None:
Other:

In order to process your (client) application, please provide the following reports, as applicable:
Medical / physical:
School / IEP:
Rehabilitation Engineering:
Neuropsychological:
Neurological:
Physical Therapy:
Occupational Therapy:
Speech Therapy:
Other:

Name of person completing the application:
Company / Organization:
Street Address:
City:
State:
Zip Code:
Phone:
Email:	(E-mail)
Relationship to applicant:

*Applicant and / or caregiver has approved services.
Client / Caregiver Digital Signature: (Please type full name)
Date:
Need to send an attachment with your application? Please send attachments to info@c2bir.org.