Client Referral Form Client's Details Title Mr Mrs Miss Ms First Name Last Name Address City County Post Code Landline Number Please use numbers only and without spaces. Mobile Number Please use numbers only and without spaces. Nature of Injury ABI TBI Stroke Other Additional details about the injury 0 of 255 max characters Date of Birth Gender Male Female Transgender Other Email Address Preferred form of contact Phone Email Letter What Headway Black Country Services are you interested in? Carer Support Counselling Fundraising Information - Brain Injury Condition Information - Welfare, Benefits etc. Listening Ear Outreach Publicaitons Rehab Services Survivor Support Volunteering Other If you are completing this form on behalf of the person detailed above, please complete the following: Referrer First Name Referrer Last Name Referrer Address City County Post Code Organisation Name Referrer Telephone Number Please use numbers only and without spaces. Referrer Email Who should we contact initially about this enquiry? Referrer Referee Disclaimer Personal Data you provide on this form will be held and processed in accordance with our Privacy Policy. Headway Black Country Services: Information for Referrers Brain Injury Rehabilitation The Headway rehabilitation service works with survivors to relearn lost skills, learn new skills, develop insight into their condition and to improve confidence and self- esteem. The sessions provided by Headway aim to assist people with brain injury to return to community living and productive activity. This is achieved through the provision of structured sessions as part of a day opportunities programme. Our clients work to progress against their individual learning objectives and are supported through regular key working and progress reviews. Outreach Service This service is dedicated to supporting clients and carers of brain injury survivors helping them to access the specialist support and information that they need. This service is currently free, subject to availability. Brain Injury Rehabilitation The Headway rehabilitation service works with survivors to relearn lost skills, learn new skills, develop insight into their condition and to improve confidence and self- esteem. The sessions provided by Headway aim to assist people with brain injury to return to community living and productive activity. This is achieved through the provision of structured sessions as part of a day opportunities programme. Our clients work to progress against their individual learning objectives and are supported through regular key working and progress reviews. CAB With the help of the Big Lottery Reaching Communities Fund we are able to offer with our Partner Dudley Citizens Advice a free independent and confidential advice service specifically for people with Acquired Brain Injury, their families and carers This service is currently free, subject to availability. Counselling Service We are now offering a counselling service. Emotional support can be very important in helping survivors and their carers adjust to the changes that have occurred. This service is charged, although costs are being kept as low as possible. You can find out more information about the services Headway Black Country provides at: Headway Black Country Please enable JavaScript for this form to work.