Intake for Concussion ServicesReferral/Self-ReferralName(Required) First Last Date of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Email(Required) Phone Number(Required)Special considerations when contacting (e.g. prefers email, works full-time, ESL, has expressive speech delay, aphasia or other communication difficulties, best person to contact, etc.)Alternate Contact NameRelationshipAlternate Contact Phone NunberHistory of Concussion(*Please describe any relevant history)Date of Incident(Required) DD slash MM slash YYYY Participants are eligible if their concussion occurred at least 3 months ago and no more than 5 years ago.Event Description(Required)Rehabilitation Supports Received and dates if knownCommunity/Social SupportList any services/supports currently in place (e.g. Homecare, housing subsidy, financial assistance, transportation, etc.)(Required)Please comment on family and/or natural supports(Required)Medical SupportFamily DoctorPhoneFaxEmailMedical Practitioner/SpecialityPhoneFaxEmailOther Medical SpecialistPhoneFaxEmailPlease comment on any other medical or health concerns (e.g. diabetes, heart condition, seizures, mental health conditions, etc.)(Required)Is there a history of substance use, criminal charges or violent behaviour?(Required) Yes NoIf yes, further information must be provided. Attach additional documents if required****This information is collected to ensure the safety of our staff and the best outcome for our clients.Please upload supporting medical documents confirming date of concussion, and any other relevant files:Max. file size: 256 MB.Required Support(Required) Post-Concussion Support Group 1:1 Services Post - Concussion Recovery Course (Virtual) Post - Concussion Recovery Course (In-Person)Please indicate which services you requireSection BreakReferral Completed By (Please print name)(Required)Relationship (if not a self-referral)(Required)Phone(Required)FaxEmail(Required)Date(Required)
