Client Connection Form Brain Injury Association of Colorado (BIAC)

Hi, welcome to the Brain Injury Association of Colorado’s Client Connection Request Form. We provide the support, connections, and available resources that survivors of a brain injury and their support network need.

Please fill out this form if you or some you know has a brain injury-related needs. If the need is related to general resources such as housing, food, or rental assistance, please call the state resource hotline by dialing 2-1-1 or use FindHelp.org. Please note, we are not a crisis service. If you’re in need of immediate mental health support we encourage you to dial 9-8-8 which is free and confidential.

To uphold the quality of our services and enable our staff to provide the best possible support, we will ask a series of questions to ensure the person looking to connect with services will benefit from our programs.

Areas of Need and Interest

Internal Programs

Brain Injury Classes (Ex: Poetry, Art therapy)

Counseling/Therapy (Colorado Medicaid or Private Pay only)

Adaptive Recreation (Ex: Adaptive Skiing, Fishing, Bowling)

Self-Management/Skill Building (Ex: Home Skills, Vocational Support)

Support Groups (Ex: Survivor and Caregiver Specific Support Groups)

Referrals to Community Resources (through our Resource Facilitation program)

Proof of Brain Injury

Starting in 2025, because more people need services, some BIAC programs will require proof that a person has a brain injury and that it still affects their life.

To meet this requirement, BIAC accepts different types of proof.

Option 1

The first and easiest way is to take a free online brain injury screening. This tool, called the Online Brain Injury Screening and Support System (OBISSS), was created by the National Association of State Head Injury Administrators (NASHIA). It takes about 15 minutes to complete. After finishing, you will get an email with your results. You can also enter records@biacolorado.org as an email so BIAC gets your results automatically (see instructions here). If your screening shows you may have a brain injury, you can attach your results to this form, or you can wait for us to follow up if we receive them directly.

If you need help completing the screening, BIAC staff can assist you. Just call 303-355-9969 and tell them you are filling out the connection form and need help.

Option 2

The second way to show proof is by providing medical records or a letter from a doctor. This must include both proof of a past brain injury and proof that it still affects your life today.

Instructions for downloading your positive results and uploading them

How will proof of a brain injury and it's impact be submitted?(Required)

The screening tool results will be attached to this form

The screening tool results will be emailed directly to BIAC

Medical records or a letter from a doctor will be attached to this form

Medical records or a letter from a doctor will be emailed directly to BIAC

BIAC already has records of proof of brain injury on file

Completed Positive Screen(Required)

Drop files here or

Max. file size: 512 MB, Max. files: 10.

Medical Records or Letter From a Doctor(Required)

Drop files here or

Max. file size: 512 MB, Max. files: 10.

I understand that positive screening results must be emailed to records@biacolorado.org before services can be accessed(Required)

Yes, I understand

I understand that medical records or a letter from a doctor must be emailed to records@biacolorado.org before services can be accessed(Required)

Yes, I understand

I understand that BIAC must locate records on file and confirm eligibility before services can be accessed(Required)

Yes, I understand

About The Person Completing this Form

What best describes you?(Required)

An individual with a brain injury looking for support

A professional working with an individual with a brain injury

A friend or family member of a person with a brain injury

Professional Information

Name of the Professional(Required)

First Last

Company of the Professional(Required)

Phone Number of the Professional(Required)

Email of the Professional(Required)

Friend or Family Member Information

Name of the Friend or Family Member(Required)

First Last

Relationship of the Friend/Family Member to the Individual with a Brain Injury(Required)

Phone Number of the Friend or Family Member(Required)

Email of the Friend or Family member(Required)

Individual With A Brain Injury Information

Name of the Individual with a Brain Injury(Required)

First Last

Phone Number of the Individual with a Brain Injury(Required)

Phone number unknown?

I do not know the phone number for the person with a brain injury

Email of the Person with a Brain Injury(Required)

Email unknown?

I do not know the email for the person with a brain injury

Person-Centered Statement

At the Brain Injury Association of Colorado, we’re committed to a person-centered approach that supports brain injury survivors in their healing and recovery. We value understanding each client’s unique goals, even when they differ from what caregivers or professionals might envision. By empowering clients to actively participate in their recovery journey, we enhance the quality of our resources and contribute to meaningful outcomes.

To ensure we respect clients’ perspectives and confidentiality:

Intakes must be completed directly with the client unless written approval is provided for a secondary party to participate.
A signed release of information form is required to maintain confidentiality and facilitate future communication.
For clients unable to manage their affairs, a representative with appropriate legal documentation (e.g., guardian or conservator) must be identified.

Thank you for your dedication to improving the lives of those affected by brain injuries.

Acknowledgement 1(Required)

I acknowledge that I have read the above Person-Centered Statement

Acknowledgement 2(Required)

I acknowledge that due to HIPAA requirements, if a signed release form is not provided (attach below), BIAC will not give updates to the referring party about the services provided or the contact had with the person with a brain injury. This includes any updates on the status of BIAC's ability to connect with the person referred

Optional - Release of Information (ROI) Upload

If you have one or more releases of information that you would like to provide to BIAC that will allow us to speak with a 3rd party on behalf of the individual with a brain injury, upload them here.

Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 512 MB.

Click here to access a copy of the BIAC ROI

Injury History Details

To the best of your knowledge, please select the type of brain injury you (or the individual you are referring) sustained. If you are uncertain, a Resource Facilitator will assist you during the intake process. Select the option that seems most appropriate for now. If you are unsure about the date, choose the closest date that you think is accurate.

Injury Information

Month of Injury	Year of Injury	Cause of Injury	Actions

There are no Injuries.

Optional - Medical Records or Other Documentation about Brain Injury

Please upload any additional documentation you have, such as medical records, assessments, neuropsychological evaluations, or other helpful information.

Accepted file types: jpg, png, pdf, docx, Max. file size: 512 MB.

Referral Source Details

How did you hear about the Brain Injury Association of Colorado?(Required)

Specific Name of Referral Source Above(Required)

Additional Information about the Individual with a Brain Injury

Is the person with a brain injury currently unhoused?(Required)

Yes

No

Unknown

Is the person with a brain injury currently in custody?

No

Yes

Please note: In order to connect an individual who is currently in custody, the person must be released an in the community within 30 days of the connection request.

Custody Policy Acknowledgment(Required)

I acknowledge the policy and confirm that the individual being connected will be in the community and able to access services within 30 days

Address(Required)

Street Address Address Line 2 City State ZIP Code

Street address unknown?

I do not know the address for the person with a brain injury

Colorado County where the Individual with a Brain Injury is Located(Required)

Birthdate(Required)

Race/Ethnicity(Required)

Preferred Language(Required)

Preferred Language - Please define if you selected "other"(Required)

Gender of the Individual with a Brain Injury(Required)

Preferred Pronouns

Ex: She/Her/Hers, They/Them/Theirs, Xe/Xem

Annual Income Range(Required)

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(Required)

Current Health Insurance(Required)

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

Next Steps

Who should BIAC contact first regarding this connection request?(Required)

Is the individual with a brain injury being referred aware of this referral?(Required)

Any other information you would like to provide?

Name

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

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Client Connection Request Form

Client Connection Request Form

Areas of Need and Interest

Proof of Brain Injury

About The Person Completing this Form

Professional Information

Friend or Family Member Information

Individual With A Brain Injury Information

Injury History Details

Referral Source Details

Additional Information about the Individual with a Brain Injury

Next Steps

Brain Injury Support

How to Help Us

Professional Resources

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