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Patient Name *

First

Last

Patient Date of Birth

Email *

Phone number *

Location *

Relative to contact if unable to speak?

Who referred you?

If no one, how did you hear about us?

How long ago did the accident happen? What happened?

Were you in the hospital? Was surgery performed?

What were your initial symptoms?

What are your current symptoms? (select all that apply)

Any other symptoms?

Are you in a wheelchair?

Yes
No
No, but require assistance walking

Are you able to verbally communicate?

Yes, I can speak well
Yes, but speaking is difficult
I rely on written communication
No, I cannot speak or write and I require assistance

Are you able to eat on your own?

Yes
No, I have a feeding tube
No, I require assistance

Who is your primary care doctor?

Do you have a diagnosis?

Are there any mental health conditions in the family?

Are you seeing a psychiatrist?

What medications/supplements are you taking?

Do you have any allergies? If so, to what drugs or substances?

Do you have any other medical history? Any previous surgeries?

What treatments have been performed? Any improvements since accident?

Would you like to know more about: (select all that apply)

Any other questions, comments, or concerns?

Scheduling with TBI Therapy

Your answers will be reviewed by our team and we will follow up with you however you choose below. Before any email, phone, or in-person correspondence, we ask all patients to review the educational webinars offered at tbitherapy.com/webinars.

Schedule with TBI Therapy *

I would like to schedule a TBI Therapy in-person consultation at the Basalt, CO location - $ 350.00
I would like to schedule a 30-min phone call with a TBI Therapy provider - $ 300.00
I would to schedule a baseline Cognitive Assessment Test (includes 5 subsequent scans) - $ 50.00
I have 1-2 specific questions that can be answered by email before I commit to treatment. - $ 0.00

Please write out the 1-2 specific questions or comments you have for a TBI Therapy provider.

Before corresponding with TBI Therapy, I will review the educational webinars offered at tbitherapy.com/webinars *

Yes

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