NeuroSparks Retreat 2025
The Brain Injury Association of Ohio and Cleveland State University are hosting NeuroSparks July 28 - 30, 2025. This event is for adults (18 years old or older) who have sustained a brain injury, have plateaued in their rehabilitation and are looking for a "boost". This innovative program unites multiple disciplines of students ( Physical Therapy, Occupational Therapy, Speech Therapy and more) to come together and offer individuals a complete evaluation and a personalized home going plan. This plan will include suggestions for how to progress your rehabilitation at home after the program. Included in participation in the program you will receive an Tablet loaded with apps recommended by your evaluation team. The three-day intensive program is designed to help survivors “spark” their recovery by building new skills in an interactive, engaging, and positive way. In addition to helping brain injury survivors, there will be specialized sessions designed to help caregivers—as the daily challenges of providing care for TBI survivors can be overwhelming, stressful and isolating. Space is limited and spots will be filled on a first come, first serve basis. *Application will close June 6, 2025 and applicants will be notified by the end of June regarding their status.
Requirements to Participate:
- Individual with brain injury must be 18 years or older. -You must have a caregiver that can attend all three days of the program with you. -You must be able to travel to Cleveland State University's campus all three days, and be a maximum of 45 miles away from the campus.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you live alone?
Please Select
Yes
No
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Nonbinary
Prefer not to answer
Primary Language
Highest Level of Education you completed
Please Select
Some High School
High School
Some College
College
Graduate Degree
Are there any religious or cultural beliefs that impact your care that we need to be aware of?
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Next
Do you have a caregiver that can attend with you all 3 days?
Yes
No
Caregiver's Name
First Name
Last Name
What is your caregiver's relationship to you?
Caregiver's Email
example@example.com
Caregiver's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver's Phone Number
Please enter a valid phone number.
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Next
When was the date of your Brain Injury
-
Month
-
Day
Year
Date
How did you obtain your brain injury?
Please rate how difficult these items are for you since your injury.
No Problem at All
Mild problem but does
not interfere with
activities
Mild problem; interferes
with activities 5-24% of
the time
Moderate problem;
interferes with activities
25-75% of the time
Severe problem;
interferes with activities
more than 75% of the
time
Hearing
Aphasia (difficulty finding words or understanding language)
Speech Intelligibility
Reading
Writing
Thinking
Memory
Do you have difficulty swallowing?
Yes
No
Do you have any food allergies or restrictions?
Are you on any special diet? (Feeding tube, pureed foods etc)
Do you have any non food allergies?
Please tell us about any hospitalizations or surgeries in the last year.
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Please list any additional medical diagnosis you have
Have you ever been diagnosed with anxiety?
Yes
No
Have you ever been diagnosed with depression?
Yes
No
Have you ever been diagnosed with bipolar disorder?
Yes
No
Have you ever been diagnosed with psychotic disorder?
Yes
No
Have you ever been diagnosed with OCD?
Yes
No
Have you ever been diagnosed with ADHD?
Yes
No
Have you ever been diagnosed with a sleep disorder?
Yes
No
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Do you use any of the following drugs
Marijuana
Cocaine
Opiates
Benzodiazepines
None
Have you ever been arrested or convicted of any crime? If yes, please describe
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In an effort to create a positive plan of care for you, We would like some information regarding any recent therapies you have received. This will help us to better serve you in the program.
Have you had therapy recently (within the last year)? If yes, please select the types of therapy you have had.
Physical Therapy
Occupational Therapy
Speech Therapy
None
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Do you give us permission to contact your previous therapist?
Yes
No
If you have had therapy recently - please tell us the name of the company and therapist.
Therapist's phone
Please enter a valid phone number.
Therapist's email
example@example.com
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Next
Mobility
The following questions are about moving aroundinside your home.
Please tell us how you get around
Independently walk
Walk with assistance
Use a walker
Use a cane
Use a manual wheelchair
Use a power wheelchair
Is your ability to move around limited by any of the following (Check all that apply)
Fatigue
Illness
Physical Impairment
Pain
Not Limited
How much help from another person do you need to move around your home?
A great deal of assistance
A moderate amount of assitance
Just a little assistance
No Assistance
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Dressing
The next questions are about dressing. Dressing includes selecting, putting onand taking off clothing, and changing clothing during the day.
How much time do you need to get dressed on a typical day?
More than 20 minutes
10 to 20 minutes
Less than 10 minutes
Is your ability to get dressed limited by any of the following (Check all that apply)
Fatigue
Illness
Physical Impairment
Pain
Not Limited
How much help from another person do you need to get dressed?
A great deal of assistance
A moderate amount of assitance
Just a little assistance
No Assistance
How often do you use accommodations, adaptations, or special equipment when dressing?
All of the time
Most of the time
Some of the time
A little of the time
Never
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Bathing
The following questions are about bathing. Bathing includes taking a shower, abath, or a sponge bath.
How much time do you need to bathe on a typical day?
More than 20 minutes
10 to 20 minutes
Less than 10 minutes
Is your ability to bathe limited by any of the following (Check all that apply)
Fatigue
Illness
Physical Impairment
Pain
Not Limited
How often do you use accommodations, adaptations, or special equipment to bathe?
All of the time
Most of the time
Some of the time
A little of the time
Never
Other Activities of Daily Living - Please describe how you complete the following activities in your daily life. Select one answer for each item.
*
Independent without any assistance or devices
With a little assistance from someone else
With a lot of assistance from someone else
Someone else handles this entirely for me
Going to the Restroom
Grooming (Shaving, brushing your teeth)
Preparing Meals
Managing your Medications
Managing your finances
Driving
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These questions are about your thinking abilities now (including the past week).
*
Not at all
Slightly
Moderately
Quite
Very
How satisfied are you with your ability to concentrate, for example
when reading or keeping track of a conversation?
How satisfied are you with your ability to express yourself and
understand others in a conversation?
How satisfied are you with your ability to remember everyday things, for
example where you have put things?
How satisfied are you with your ability to plan and work out solutions to
everyday practical problems, for example what to do when you lose
your keys?
How satisfied are you with your ability to make decisions?
How satisfied are you with your ability to find your way around?
How satisfied are you with your speed of thinking?
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These questions are about your emotions and view of yourself now(including the past week).
*
Not at all
Slightly
Moderately
Quite
Very
How satisfied are you with your level of energy?
How satisfied are you with your level of motivation to do things?
How satisfied are you with your self-esteem, how valuable you feel?
How satisfied are you with the way you look?
How satisfied are you with what you have achieved since your brain
injury?
How satisfied are you with the way you perceive yourself?
How satisfied are you with the way you see your future?
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These questions are about your independence and how you function in daily life now (including the past week).
*
Not at all
Slightly
Moderately
Quite
Very
How satisfied are you with the extent of your independence from
others?
How satisfied are you with your ability to get out and about?
How satisfied are you with your ability to run your personal finances?
How satisfied are you with your participation in work or education?
How satisfied are you with your participation in social and leisure
activities, for example sports, hobbies, parties?
How satisfied are you with the extent to which you are in charge of your
own life?
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Next
These questions are about your social relationships now (including the past week)
*
Not at all
Slightly
Moderately
Quite
Very
How satisfied are you with your ability to feel affection towards others,
for example your partner, family, friends?
How satisfied are you with your relationships with members of your
family?
How satisfied are you with your relationships with your friends?
How satisfied are you with your relationship with a partner or with not
having a partner?
How satisfied are you with your sex life?
How satisfied are you with the attitudes of other people towards you?
These questions are about how bothered you are by your feelings now(including the past week).
*
Not at all
Slightly
Moderately
Quite
Very
How bothered are you by feeling lonely, even when you are with other
people?
How bothered are you by feeling bored?
How bothered are you by feeling anxious?
How bothered are you by feeling sad or depressed?
How bothered are you by feeling angry or aggressive?
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These questions are about how bothered you are by physical problemsnow (including the past week).
*
Not at all
Slightly
Moderately
Quite
Very
How bothered are you by slowness and/or clumsiness of movement?
How bothered are you by effects of any other injuries you sustained at
the same time as your brain injury?
How bothered are you by pain, including headaches?
How bothered are you by problems with seeing or hearing?
Overall, how bothered are you by the effects of your brain injury?
What are your goals of participating in this program?
Please tell us a little bit about any hobbies or special interests you may have.
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