Healthy Minds Registration April 2026
Thank you for your interest in the Healthy Minds Program! This program is intended for survivors of brain injury and their caregivers. You can use this form to register one individual, if you need to register more than one, you will need to complete the form again. The program is free and offered virtually. If you need assistance with familiarizing yourself with the Zoom technology please call us at 614-481-7100 and we will set up a time to practice with you. Program kits including supplies needed to participate will be mailed to you after attending the first or second class of the session. To demonstrate to our funders that this program is beneficial, you will be asked to complete a survey related to your health and quality of life, now at registration and again at the end of the program. All participants that attend 70% or more of the sessions will be entered into a raffle for a $50 Amazon gift Card. In order to qualify you must attend the required number of sessions and you must complete the end of program survey. If you have questions about the program before registering, please call us at 614-481-7100 or email us at member@biaoh.org. Thank you!
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
Gender
Please Select
Male
Female
Non-binary
Choose not to answer/other
I am a
Survivor
Caregiver
Other
How did you hear about Healthy Minds?
Social Media
A Medical Professional
BIAOH Newsletter
A Friend
A Support Group
Other
Answer the following question regarding your health
Excellent
Very Good
Good
Fair
Poor
In general would you say your health is:
The following questions are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? If so, how much?
Yes, limited a little
Yes, limited a lot
No, not limited at all
MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf:
Climbing SEVERAL flights of stairs:
During the PAST 4 WEEKS have you had any of the following problems with your work or other regular activities AS A RESULT OF YOUR PHYSICAL HEALTH?
Yes
No
Accomplished less than you would like
Were limited in the KIND of activity or work
During the PAST 4 WEEKS, were you limited in the kind of work you do or other regular activities AS ARESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)?
Yes
No
Accomplished less than you would like
Didn’t do work or other activities as CAREFULLY as usual
During the past 4 weeks
Not at all
A little bit
Moderately
Quite a bit
Extreamly
How much did PAIN interfere with your normal work (including both work outside the home and housework)?
The next three questions are about how you feel and how things have been DURING THE PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the PAST 4 WEEKS –
All of the time
Most of the time
A good bit of the time
Some of the time
A little bit of the time
None of the time
Have you felt calm and peaceful?
Did you have a lot of energy?
Have you felt downhearted and blue?
During the PAST 4 WEEKS, how much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
A good bit of the time
Some of the time
A little bit of the time
None of the time
How much of the time has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)?
Submit
Should be Empty: