See if You Qualify for Treatment for TBI! Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastPatient Date of BirthEmail *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)HeadacheHead PressureNeck PainNausea or vomitingDizzinessBlurred VisionBalance ProblemsSensitivity to lightSensitivity to noiseFeeling slowed downFeeling like “in a fog”“Don’t feel right”Difficulty concentratingDifficulty rememberingFatigue or low energyConfusionTrouble falling asleepMore emotionalIrritabilitySadnessNervous or anxiousAny other symptoms?Are you in a wheelchair?YesNoNo, but require assistance walkingAre you able to verbally communicate?Yes, I can speak wellYes, but speaking is difficultI rely on written communicationNo, I cannot speak or write and I require assistanceAre you able to eat on your own?YesNo, I have a feeding tubeNo, I require assistanceWho 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)Stem cells and platelet rich plasmaHyperbaric oxygen therapyCranial osteopathyNutritional supplements and dietary guidlinesIV and intranasal therapiesAdjunctive treatmentsBrain imaging and mappingAny other questions, comments, or concerns?Scheduling with TBI TherapyYour 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 - $ 350.00I would like to schedule a 30-min phone call with a TBI Therapy provider - $ 300.00I would to schedule a baseline Cognitive Assessment Test (includes 5 subsequent scans) - $ 50.00I have 1-2 specific questions that can be answered by email before I commit to treatment. - $ 0.00Please 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 *YesCustom Captcha * = MessageSubmit
