Lived Experience Team Application

Lived Experience Team

Fill this out to join our foundation’s team of lived experience experts
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Privacy Policy

www.braincarecatalyst.com
Please reach out and read our Privacy Policy in order to understand how your information is used and and kept confidenital and check below if you accept the policy.
Sex
Which race or ethnicity best describes you?
Preferred way to contact

PhoneEmailPostAny
Birth Date

MonthDayYear
Membership Rules
1. Membership is available to anyone 23 years of age or older who has been diagnosed as having had a concussion or other traumatic brain injury.
2. You must provide information about yourself and your injury. This information will be kept confidential by the Brain Care Catalyst Foundation.
Date of Head Injury

MonthDayYear
Who said that you had a concussion or traumatic brain injury?
Please indicate what symptoms you experienced after your injury.

Sleep difficultiesHeadacheSensitivity to lightDizzinessVomitingAnger managementDifficulty concentratingRinging earsVision distrubancesImbalanceMemory challengesCrying/Being more emotionalDepressionSexual dysfunctionOther
Where did you hear about us?

A Friend or colleaugeGoogleFacebookOther
Once you submit your application, we will contact you shortly to complete your membership application.

Thank you!
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Lived Experience Team