AHEAD Registration Form - June 2026
Thank you for your interest in AHEAD: Achieving healing through education, accountability, and determination using a psycho-educational curriculum for traumatic brain injury. Topics covered will include: Understanding TBI & symptom recognition, memory skills & goal setting, emotion regulation, communication, TBI and anger, grief, and STOP to think and why it is important.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. Sessions will be June 18 - July 23 on Thursdays at 5:00 pm.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you participated in a BIAOH program before?
*
Yes
No
How did you hear about this program?
*
What is your gender?
*
Please Select
Man
Woman
Non-Binary
Prefer not to say/Other
Are you a veteran?
*
Yes
No
What is your role?
*
Brain Injury Survivor
Caregiver
Age
*
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Answer the following questions regarding your memory
*
Rows
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I have confidence in my ability to remember things
I feel unhappy when I think about my memory ability
I worry that I will forget something important
I worry about my memory ability
I am generally satisfied with my memory
Answer the following questions regarding communication/emotional regulation
*
Rows
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I feel frustrated when others disagree with me
I’m aware of the effect my tone of voice and body language have on others.
I express my thoughts clearly when speaking.
I often feel tense, stressed, anxious, or angry when discussing important issues with my partner
I am generally satisfied with my memory
Answer the following questions
*
Rows
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I feel confident communicating my needs
I have the skills I need to remain calm in emotional situations
I feel confident in identifying my emotions
I am able to set realistic goals and follow through
I am able to recognize symptoms of brain injury
Submit
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