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Apply For Services!

When submitting your application, you can choose to fill out the electronic version below or fill out one of our physical copies. There is no need to fill out both.

If you need assistance with your application, please call us at 804-386-0925 or email us at info@communitybraininjury.org.

Click Here!

Option 1: Upload Your Application

Click Here!

Option 2: Fill Out Our Online Form

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Option 1: Upload Your Completed Application

Download and fill out your application. Click here to download it. When complete, upload it below.

Upload Your Form Here

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

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Option 2: Fill Out the Form Below

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Step 1 of 4

25%

Service Area and Program Interest

In which service area does the individual reside?*

Metro Richmond

Hampton Roads Peninsula

Middle Peninsula

Tri-Cities & Surrounding Area (Prince George, Surry, & Dinwiddie Counties)

What program is the individual interested in?*

Clubhouse Services

Case Management Services

Information About Person Needing Services

Full Name*

First Last

M.I.

Primary Phone*

Address*

Street Address Apartment/Unit # City State / Province / Region ZIP / Postal Code

Emergency Contact*

Emergency Contact Phone*

Date of Birth*

Gender*

Who referred you to CBIS?

Affiliation

Affiliate Phone

Has the individual served in the military?*

Yes

No

Brain Injury Information

Date of Brain Injury*

How was the brain injury acquired?*

If Other was selected, please describe here*

Please provide any details you wish to provide about your brain injury

Lost consiousness?*

YES

NO

Unknown

If yes, length of coma?*

Less than 24 hours

24-48 hours

More than 48 hours

Unknown

Medical Information

Describe medical/health problems not related to brain injury including diagnosis and current treatment*

Is there a history of seizures?*

YES

NO

Unknown

Date of last seizure*

Please describe seizures*

Primary Care Physician

Phone Number

Neurologist

Phone Number

Other doctors or medical providers?

Pharmacy Name

Phone Number

Current Medications

Please list any current medications/prescriptions

Medication Name

Dosage

Frequency

Reason

Health Insurance

Currently insured?*

YES

NO

Unknown

Provider?*

Medicaid

Medicare

Private/Other

Unknown

Legal Information

Do you have a legal representative?*

YES

NO

Unknown

Type of Legal Representative*

Name*

Relationship*

Phone Number*

Services

Has the individual needing services ever had any of the following?

History of substance or alcohol abuse*

YES

NO

Unknown

If YES, is individual actively involved in a treatment program?*

YES

NO

Unknown

If Yes, has individual completed a treatment program?*

YES

NO

Unknown

When was the last time substance or alcohol was used?*

Does the individual currently receive counseling, psychological, or psychiatric services?*

YES

NO

Unknown

If Yes, please describe diagnoses and current treatment*

Please describe any additional mental health history not noted above

Has the individual ever been arrested or convicted of a crime?*

YES

NO

Unknown

Criminal History does NOT exclude an individual from services

If Yes, please describe criminal history*

Please describe current involvement with judicial system (if any)

Employment Services

Currently employed?*

YES

NO

Employer*

Job Title*

Currently working with VR services through DARS?*

YES

NO

If Yes, VR Counselor Name*

Currently working with a Job Coach?*

YES

NO

If Yes, Job Coach Name*

Service Needs Assessment

Please rate the abilities of the individual needing services. Use the rating scale below to check the appropriate box.

1 - Needs Total Help | 2 - Needs significant help | 3 - Needs some help and supervision | 4 - Can complete but needs supervision | 5 - Fully independent, no help needed

Financial planning and paying bills*

1

2

3

4

5

Time Management*

1

2

3

4

5

Decision Making*

1

2

3

4

5

Housekeeping (household chores, errands*

1

2

3

4

5

Movement*

1

2

3

4

5

Using and Arranging Transportation*

1

2

3

4

5

Speech, Language, Communication*

1

2

3

4

5

Self-care (bathing, dressing, etc.)*

1

2

3

4

5

Learning New Skills*

1

2

3

4

5

Please check the services for which assistance is needed.*

Brain Injury Education

Finding a Place to Live

Social and Recreational Opportunities

Transportation

Home skills

Finding or Keeping a Job

Problem Solving

Mental Health Services

Social Skills

Medical Appointments and Referrals

Budgeting and Money Management

Applying for Benefits

Medication Management

Volunteer Opportunities

Increasing Productive Activity

Coping with memory difficulty

Acquiring Assistive Technology

Anger Management

Impulse Control

Homeless Service

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Name

This field is for validation purposes and should be left unchanged.

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Community Brain Injury Services is a non-profit organization specializing in the recovery of those struggling with traumatic brain injury. Based in Richmond, Virginia and servicing both the greater Richmond area and Hampton Roads, Community Brain Injury Services helps its members reclaim independence and function in their daily lives.

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CARF accreditation shows a program’s quality, transparency, and commitment to the satisfaction of the persons served. CARF International is an independent, non-profit accreditor of health and human services.

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Contact Info

9211 Arboretum Pkwy, Suite 100
Richmond, VA 23236

804.386.0925

info@communitybraininjury.org

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