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 — Contact Person Information
Name of Person Completing the Referral
*
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.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
How did you hear about our program?
*
Brain Injury Association of Ohio (BIAOH) email/newsletter
BIAOH website
Social media (Facebook, Instagram, LinkedIn)
Healthcare provider (doctor, therapist, hospital, rehab center)
School or educator (teacher, school staff, counselor)
Community organization / nonprofit
Support group
Friend or family member
Previous BIAOH program or event
Conference, training, or outreach event
Google or online search
Flyer, brochure, or printed materials
Case manager / social worker
Vocational rehabilitation (OOD or similar)
Other (please specify)
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Name of Person who referred you
*
First Name
Last Name
Organization of Healthcare Professional
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Consent to contact the referring party
Why We Ask for This Permission To best support you (or your child), we often work closely with others involved in your care—such as healthcare providers, school staff, therapists, and community partners. This collaboration helps us better understand your needs, reduce gaps in communication, and provide more coordinated, effective support.Your permission allows us to share and receive relevant information with these individuals so we can work together to help you achieve your goals. This is especially important when navigating systems like healthcare and education, where teamwork can make a meaningful difference in outcomes.You are always in control of this decision. Providing consent is voluntary, and you may change your mind at any time.
I understand this may include sharing relevant health, educational, and personal information as needed to coordinate services and supports, in accordance with the HIPAA and FERPA. I understand that:I may revoke this authorization at any time in writing, except to the extent that action has already been taken based on this consent.This authorization is voluntary, and I may refuse to sign it without affecting eligibility for services.Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA or FERPA.
I authorize the Brain Injury Association of Ohio (BIAOH) and its representatives to communicate with the individual(s) listed in this form regarding my (or my child’s) care, services, and program participation
*
Yes
No
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If the participant is under 18: I confirm that I am the parent or legal guardian of the minor participant and have the legal authority to provide this authorization on their behalf.
*
Yes
No
Participant Age
*
18 or older
Under 18
Duration of Consent
*
End of program participation
Specific date (please specify below)
Until revoked in writing
Expiration Date
-
Month
-
Day
Year
Date
Participant or Parent/Legal Guardian Signature
*
Printed Name of Participant or Parent/Legal Guardian
*
Relationship to Participant
Please Select
Parent
Legal Guardian
Other (please specify)
Date Signed
*
-
Month
-
Day
Year
Date
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SECTION 2 — Student Information
Student Name
*
First Name
Last Name
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Consent to Communicate with Third Party
*
Submit Referral
Should be Empty: