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2277 Highway 36 West, Suite 200 Roseville, MN 55113-3830
Phone: 612-378-2742
Toll Free: 1-800-669-6442
Fax: 612-378-2789
E-Mail:info@braininjurymn.org
Hours: Monday-Friday, 8 a.m. to 4:30 p.m.


Authorization to Participate in Resource Facilitation

As part of your rehabilitation, we offer follow-up services through the Minnesota Brain Injury Alliance/Minnesota Stroke Association Resource Facilitation Program. This confidential and voluntary telephone follow-up service DOES NOT REPLACE any medical or rehabilitation follow-up care that you may need. It is intended to provide you and your family with information about brain injury or stroke and assistance in accessing services and supports.

Participation begins on the date signed. A Resource Facilitator will contact you by telephone approximately six (6) weeks from the time you return this form. You can also call us at 612-378-2742 or 800-669-6442.


Contact Information

Please fill out the following information so that we may contact you.

Name:*
Address:*
City:*
State:*
Zip:*
County (for MN):
Daytime Phone:*
Evening/Cell Phone:
Fax:
E-mail:*
Best time to call:
Date of Birth:
Gender:   
Preferred Language:
I have a:   
Cause of Injury:
Date of Incident:
Date of Discharge:

Caregiver/Guardian Information

If you are a caretaker or a guardian for the person listed above, please fill out the information below.

Caregiver or Guardian:
Relationship to Above:
Caregiver Organization:
Caregiver Address:
Caregiver City:
Caregiver State:
Caregiver Zip:
Caregiver Daytime Phone:
Caregiver E-mail:

Caregiver/Guardian Information

Professional completing this Referral (Social Worker, Discharge Planner, Health Care/Rehabilitation Professional, etc.)

Name of Professional:
Title:
Organization:
Email:
Phone:

Comments:

Authorization