Healthy Minds Registration October 2026 Tuesdays at 6pm Starting October 20, 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. Program kits (boxes) including supplies needed to participate will be mailed to you after attending the first or second class of the session. If you have questions about the program before registering, please call 380-799-5181 or email us at help@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.
Format: (000) 000-0000.
Have you participated in Healthy Minds before?
*
Yes
No
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
What is one health or wellness goal you'd like to work on in this session?
*
Which area(s) of wellness are you most interested in?
*
physical
emotional
social
financial
environmental
intellectual
spiritual
occupational
creative
recreational
What are your biggest challenges right now?(fatigue, memory, motivation, pain, transportation, finances, etc)
*
What gets in the way of taking care of your health?
*
Answer the following question regarding your health
Rows
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?
Rows
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?
Rows
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)?
Rows
Yes
No
Accomplished less than you would like
Didn’t do work or other activities as CAREFULLY as usual
During the past 4 weeks
Rows
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 –
Rows
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.)?
Rows
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: