Get Calgary Brain Injury Program Referral Form - Alberta Health Services

The Calgary Brain Injury Program Referral Form is essential for facilitating access to rehabilitation services for individuals affected by brain injuries. This guide provides clear and supportive instructions for users to complete the form online, ensuring all necessary information is accurately captured.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient demographics. This includes the personal health number, date of referral, surname, first name, address, city/town, and postal code. Make sure to double-check these entries for accuracy.
3. Fill in the telephone number and referral source. If applicable, provide the family physician's contact information, including their name, phone number, and fax number.
4. Indicate the spoken language of the patient and provide information for a family or other contact, including their relationship to the patient.
5. Answer whether an interpreter is required and provide the reason for referral, including the diagnosis and date of injury.
6. Specify the cause of the injury from the available options such as motor vehicle collision, fall, or other. Include any co-morbid conditions that may apply.
7. Detail the functional concerns of the patient, selecting any applicable options from the list provided.
8. Outline the goals for rehabilitation, providing details if available, such as the length of hospital stay and medical stability status.
9. Document the current functional status by indicating the patient's activity tolerance, mobility aids, and necessary community programs.
10. Outline the psychosocial concerns, living situation, and decision-making status, providing detailed information as necessary.
11. Fill in the vocational status and income source information to give a complete picture of the patient’s circumstances.
12. Specify the requested actions for the rehabilitation services and document any therapies requested, if known.
13. Finally, confirm whether the client is aware and agreeable to the referral and provide any additional documentation if available.
14. Once all sections are completed, review the form for accuracy. Save changes, download, print, or share the form as needed.

Complete the Calgary Brain Injury Program Referral Form online today for timely access to necessary rehabilitation services.