Concussion/Moderate-Severe Brain Injury Referral FormReferral for Brain Care Centre (BCC) ServicesReferralIndividual with Brain Injury InformationName(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 NunberCommentsHave you ever been a BCC, NABIS (Northern AB Brain Injury Society) or EBIRS (Edmonton Brain Injury Relearning Society) client before?(Required) Yes NoIs the individual PDD funded?(Required) Yes NoIf yes, person is NOT eligible for Brain Care Centre services.Alternative Decision-Making Information (if applicable)Guardian Private Co-Decision Making Supported Decision Making PublicGuardian NamePhoneTrustee (Do you make your own financial decisions?) Private PublicTrustee NamePhoneOther (Enduring Power of Attorney, Personal Directive)NamePhoneHistory of Acquired Brain Injury(*acquired brain injury means damage to the brain which occurs after birth and is not related to congenital or degenerative disease)Date of Incident(Required) DD slash MM slash YYYY Event Description(Required)Type of Injury (i.e., stroke, tumor, hematoma, etc.)(Required)Hospital of Admission and dates if knownRehabilitation 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.Required SupportPlease indicate supports/services required(Required)Medical Documentation of Acquired Brain InjuryBefore an individual is eligible for service, BCC requires medical documentation of the acquired brain injury. As Brain Care Centre does not have access to NetCare, please send medical documentation on file. This can include (but is not limited to): a neuropsychological assessment, discharge summary, CT scan or MRI with interpretation of results, diagnosis from medical doctor, rehabilitation reports, etc.File UploadMax. file size: 256 MB.Medical Documentation(Required) Attached Need assistance obtaining medical documentation******Please note hospital(s) admission(s)/specialist(s) name and contact information/family doctor and contact information if you are not able to provide medical documentation and will need assistance obtaining it:Referral Completed By (Please print name)(Required)Relationship (if not a self-referral)(Required)Phone(Required)FaxEmail(Required)Date(Required)Referrals and medical documentation will be kept for 1 year after which it will be confidentially destroyed if no follow through or contact. By submitting this form you agree that we may keep confidential and secure files with your information, both in paper form and in electronic form on a secure database.
