Initial Client Referral Form

Client's Details

Who is this enquiry for?

Title

Name

First Last

Address

Street Address Address Line 2 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

Additional details about the injury

Date of Birth

Gender

Email Address

Preferred form of contact

What Headway Black Country Services are you interested in?

Please hold alt (Windows) or cmd (Mac) on your keyboard to select multiple answers.

If you are completing this form on behalf of the person detailed above please complete the following:

Referrer Name

First & Last

Referrer Address

Street Address Address Line 2 City County Referrer Post Code

Organisation Name

Referrer Telephone Number

Please use numbers only and without spaces.

Referrer Email Address

Who should we contact initially about this enquiry?

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.

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