Brain Injury Association of Ohio (BIAOH) Return to Learn Program Referral Form
Please complete this referral form for the Brain Injury Association of Ohio Return to Learn Program. This program supports students recovering from brain injury by providing coordination, guidance, and resources to help ensure a successful transition back to school. Once received, a staff member will contact you within 48 business hours.
SECTION 1 — Referring Person Information
Name of Person Referring
*
First Name
Last Name
Role/Title
*
Please Select
School Staff
Healthcare Provider
Parent/Guardian
Therapist/Rehabilitation Professional
Case Manager
Other
Organization / School / Agency Name
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Preferred Contact Method
Phone
Email
SECTION 2 — Student Information
Student Name
*
First Name
Last Name
School District
*
School Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Grade
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Postsecondary
SECTION 3 — Injury Information
Date of Injury
*
-
Month
-
Day
Year
Date
Type of Brain Injury
Concussion / Mild TBI
Moderate/Severe TBI
Acquired Brain Injury
Stroke
Unknown / Not yet diagnosed
Brief Description of Injury or Current Concerns
SECTION 4 — Consent & Follow-Up
I give permission for BIAOH staff to contact me regarding this referral.
*
I give permission for BIAOH staff to contact me regarding this referral.
Additional Notes or Information
Submit Referral
Should be Empty: