BIA OF VIRGINIA

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1-800-444-6443

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BIAA HOME : VIRGINIA : RESOURCE REQUEST FORM

Resource Request Form

If you prefer to print out this form and mail it to us, click here - otherwise please complete the form below:

* Required

Title

First Name *

Last Name *

Email Address *

Home Address *

City *

State *

Zip Code / Postcode *

Country *

Home Phone

Cell Phone

Are you a current BIAV member? *

To help us choose the most relevant information, please complete the following:

I am a: (please select one)*
Person with a brain injury
–
Family member of someone with a brain injury

Specify your relationship:

Name of person with brain injury:

Service provider

Profession:

When did the brain injury occur? (Month / Year)

What was the cause and type of brain injury?

Date of birth of the person with brain injury?

Topic List *

General brain injury information
Mild brain injury or post-concussive syndrome
Severe brain injury or coma
Behavioral consequences of brain injury
Emotional consequences of brain injury
Managing behavior after brain injury
Cognitive consequences of brain injury
Managing cognitive difficulties after brain injury
Speech and language disorders after brain injury
Headaches
Epilepsy or seizure disorders
Family issues
Spouse issues
Brain injury in children
Parenting when you have a brain injury
Rehabilitation programs
Vocational rehabilitation
Psychological and counseling issues for professionals
Financial issues and resources
Legal issues and finding an attorney
Substance abuse and brain injury
Special education in the public schools for families
Entering or re-entering higher education after brain injury
Educating students with brain injuries for teachers

Please add any additional information that will help us select the most appropriate material:

BIAV Publications & Community Resources List

BIAV Headway Newsletter (most recent edition)
Regional list of rehabilitation programs in Virginia
Statewide list of rehabilitation programs in Virginia
Regional list of brain injury treatment and assessment professionals in Virginia
Statewide list of brain injury treatment and assessment professionals in Virginia
List of attorneys experienced in brain injury cases
List of brain injury support groups in Virginia
List of Virginia Dept of Rehabilitative Services programs

May we e-mail you the materials? *

Enter Word Verification in box below *

As a non-profit organization, the Brain Injury Association of Virginia relies on the generosity of donors to make this information available to everyone who needs it, regardless of their ability to pay. Please consider a donation - if you can - to help cover the cost of printing and postage. All contributions are tax deductible. Thank You!