Survivor Referral Form

Survivor Contact Information

Name

First Last

Mobile Phone

Landline Phone

Email

Address

Street Address City State / Province / Region ZIP / Postal Code

County

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Preferred Method of Contact

Select all that apply by holding down Ctrl while selecting

Survivor Demographic Information

Date of Birth

Gender*

Race/Ethnicity*

Preferred Language*

Preferred Language - Please define if you selected "other"

Annual Income Range*

Note: This information has no impact on an individual's access to services. We serve all people regardless of income. The reason we ask this question is because many foundations and grant funders request this information for funding purposes.

Military Status*

Current Heath Insurance*

Please be as descriptive as possible. If you do not know, please write "unknown"

Survivor Injury Information

Injury History

Date of Injury	Cause of Injury
		Edit Delete
There are no Injuries.

Maximum number of injuries reached.

Please provide information about all injuries. Click "Add Injury" to begin. To add multiple injuries, simply click "Add Injury" again after each new injury. If you do not know specific injury information, please select "Unknown" when adding an injury history.

Please upload any supporting documentation here (ex: OSU TBI Screen)

Drop files here or

Have you ever sustained a brain injury in the workplace?

Yes
No

Did you receive workers compensation benefits for that injury?

Yes
No

Individual Making Referral

If you are a survivor filling out this form, skip to the next section.

Name

First Last

Mobile Phone

Landline Phone

Email

Relationship to Survivor

If we cannot get in touch with the survivor, may we contact you?

Yes
No

Business/Organization

City of Business/Organization

Criminal Justice Site (if applicable)

If the survivor being referred is involved with one of the above, please indicate which site. If they're involved with more than one site, please select the one that is most applicable.

*Note: This information does not impact eligibility for services with BIAC

Next Steps

Areas of Need

Select all that apply by holding down Ctrl while clicking

Any other information you would like to provide?

Who should BIAC contact first regarding this referral?

Is the survivor being referred aware of this referral?

*Note: if an email for the survivor is provided, a receipt of the referral will be sent to them. Please click here for information about our Privacy Practices

Yes
No

Name

This field is for validation purposes and should be left unchanged.

Survivor Contact Information

Survivor Demographic Information

Survivor Injury Information

Individual Making Referral

Next Steps

Friends & Supporters

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