Resource Request Form

Title
DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Mailing Address *

City *

State *

Zip Code / Postcode *

Country *
UNITED STATES

Is this a business address? *
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Please provide at least one phone number in case we have a question about your request:

Home Phone Number

Work Phone Number

Cell Phone Number

Are you a BIAV member? *
-- Please select -- Yes No

How did you learn about BIAV? *

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

I am a: *
Person with a brain injury

Family member of someone with a brain injury

Specify your relationship:

Name of person with brain injury:

Profession :

When did the brain injury occur?

What was the cause and type of brain injury?

Date of birth of the person with brain injury?

Topic List (please limit your selections to 10 topics)*

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
(NOTE: Regional lists will be sent based on the address you entered above.)

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

Preferred contact method *
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