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Brain Injury Coalition Request for Case Review Form

Instructions:
You may complete either the online form below or download the pdf to submit your Request for Case Review Form via Fax, Email as an attachment or via regular mail. If submitting via email, send completed form as an email attachment to: helfgom@ccf.org.

To submit via regular mail, please mail completed form to:

Marcie Moss Helfgott
2801 Martin Luther King Drive / CR 11
Cleveland, Ohio 44104-3865
Phone: (216) 448-6283
Or Fax to: (216) 791-1012

Online Submission of Request for Case Review Form
Required fields are indicated by an asterisk (*)

Date:
*Referring Agency/Person:
*Contact Phone Number:
Email Address:
*Name of Individual to be Reviewed:
D.O.B.:
Age:
Address:
Apartment/Suite:
City:
State:
Zip:
Home Phone:
Cell Phone:
Educational Level:
School(s) Attended:
Employer at time of injury:
Position:
Years Employed:
Summary of Job Responsibilities:
Date of Injury:
Nature of Injury:
Acquired Brain Injury Traumatic Injury
How did the injury occur:
Was there a loss of consciousness?
No Yes
If Yes, for how long?
Was rehabilitation provided?
 Yes No
Name of facility:
Inpatient Outpatient
Duration of Rehab:
Therapy Provided:
 PT OT Speech Psychology Neuropsychology
Did he/she complete a Neuropsychological evaluation?
Yes No
Current Medications: (Include name, dose and frequency)
Name of Family/Support Person:
Address:
Apartment/Suite:
City:
State:
Zip:
Home Phone:
Cell Phone:
Current Concerns: Identify the person’s concerns, you may not have to use all subject areas below.
Behavior:
Mood/Emotional State:
Physical Functioning:
Daily Activity Pattern:
Medical Issues:
Hygiene/Cleanliness:
Appetite:
Sleep:
Sexuality:
Medications:
Employment Issues:
How did you hear about the BIC Case Review process?