CARES Referral Form

CARES Program

AGENCY REFERRAL FORM

Name of Referring Staff/Agency:

Referring Staff/Agency Phone Number:

Referring Staff/Agency Email:

Name of Potential Participant: *

Age of Potential Participant

Cause of Brain Injury: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Primary Contact: *

Relationship:

Home Phone Number *

Cell Phone Number

Email Address

Reason for referral or identified needs: *

Concerns/Issues: *

Referrals already made on behalf of participant: (check all that apply) (optional)

Additional Comments:

I hereby authorize (referring agency listed above) to make a referral on my behalf to the BIANJ CARES program. I understand that medical history and discharge recommendations could be shared with BIANJ. I understand that this authorization will only be in effect for six (6) months from date of signature.

Participant Name: *

Was verbal consent obtained to share personal information with BIANJ: *

YES

NO

Signature of Participant or their guardian:

clear

Date of Signature/Verbal Consent: * +

For more information or questions, please feel free to contact Elizabeth Van Roten at 848-213-3380 or email evanroten@bianj.org.

Home Care Agencies	Government Agencies (SSI, Medicaid, DDD)
DVRS	Additional Therapies
TBI Fund	Other Other