HEAD INJURY ASSOCIATION'S ONLINE INTAKE

Date:    Referred By:
Name of Applicant: Telephone #
Applicant's Address:
City: State:
Date of Birth:  
Age of Injury: Cause of Injury:
Name of Person Completing Intake:
Relationship: Telephone #
Applicant's Address:
City: State:
Do you have a Legal Guardian? Yes No
If yes, Legal Guardian's Name & Telephone #
Do you have a Service Coordinator? yes no
If no, are you interested in receiving Service Coordination? Yes No
What additional programs, supports or services are you interested in?
Day Program Residential Services Recreation Program
In-home services Behavioral Support TBI Support Groups
Residential Habilitation Independent Living Skills Training CIC Services
Information and Referral Other:
Benefits
Medicaid: Yes No pending: ID# Seq#
Medicare Yes No Part A Part B ID #
Social Security Disability (SSDI) Yes No     Amount:
Social Security Income (SSI) Yes No     Amount:
Private Health Insurance Yes No     Amount:
Other:
Medical Information:
Please list any medical and psychiatric diagnosis:
Do you have history of substance abuse? Yes No
If yes, please explain:
Current Status:    
Please check off any area of difficulty you have experienced since your injury:
short term memory loss long term memory loss concentration
attention hand/eye coordination comprehension
learning new information problem solving reading
orientation to person, time, day writing hearing
visual perception judgment organization
balance spasticity paralysis
speech swallowing incontinence
sleeping fine motor skills gross motor skills
anxiety agitation aggression
impulsivity depression decreased inhibition
other (please explain)