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Minds Matter Services
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Therapy Services Planning Tool
What best describes you?
Select One
What best describes you?
Person with a brain injury
Family or friend of a person with a brain injury
Professional or medical contact
Therapy Services Planning Tool
Please enter your contact information.
What is your name?
(Required)
What is your date of birth?
(Required)
Best phone number to reach you?
(Required)
Email address?
(Required)
Therapy Services Planning Tool
What best describes your living situation?
What best describes your living situation?
(Required)
Nursing Home
Assisted Living
Currently Unhoused
Rent
Own
Other
Please explain:
(Required)
Therapy Services Planning Tool
Do you have a guardian or durable power of attorney?
Guardian or Durable Power of Attorney
Guardian
Durable Power of Attorney
Neither
Therapy Services Planning Tool
Are you covered by insurance?
Are you covered by insurance?
(Required)
Yes
I need support in gaining coverage
Please enter your insurance information
(Required)
Therapy Services Planning Tool
What is the cause of your brain injury?
What is the cause of your brain injury?
(Required)
Therapy Services Planning Tool
When did your injury occur?
When did your injury occur?
(Required)
Less than 1 year ago
1-5 years ago
6-10 years ago
10+ years ago
I'm not sure
Therapy Services Planning Tool
What support are you looking for from Minds Matter, LLC?
Select all that apply
What support are you looking for from Minds Matter, LLC?
(Required)
Cognitive Therapy
Behavorial Therapy
Physical Therapy
Occupational Therapy
Speech Therapy
Navigating Home
Other
Therapy Services Planning Tool
Who is the best person to reach out to for scheduling?
Who is the best person to reach out to for scheduling?
(Required)
Self
Someone Else
What is their name?
(Required)
Relationship to you
(Required)
Phone
(Required)
Email
(Required)
Therapy Services Planning Tool
Please enter your contact information.
What is your name?
(Required)
Phone
(Required)
Email
(Required)
Therapy Services Planning Tool
Please enter the consumer's information.
What is the consumer's name?
(Required)
What is their date of birth?
(Required)
Phone (if known)
Email (if known)
Are they currently living in a facility?
(Required)
Yes
No
What is their address?
(Required)
Therapy Services Planning Tool
Are they covered by insurance?
Covered by insurance?
(Required)
Yes
They need support to obtain insurance coverage
Unsure
Please provide insurance information (if known)
Therapy Services Planning Tool
What is the cause of this person's injury?
Cause of this person's injury?
(Required)
Therapy Services Planning Tool
When did the injury occur?
When did the injury occur?
(Required)
Less than 1 year ago
1-5 years ago
6-10 years ago
10+ years ago
Unsure
Therapy Services Planning Tool
What supports is this person wanting?
Select all that apply
What supports is this person wanting?
(Required)
Behavioral Therapy
Cognitive Therapy
Occupational Therapy
Physical Therapy
Speech Therapy
Navigating Home
Unsure
Other
Therapy Services Planning Tool
Who is the best person to reach out to for scheduling?
Best person to reach out to for scheduling?
(Required)
Consumer
Me
Other
What is the person's name?
(Required)
Phone
(Required)
Email
(Required)
Therapy Services Planning Tool
Please enter your contact information.
What is your name?
(Required)
Phone
(Required)
Email
(Required)
What organization are you with?
(Required)
Therapy Services Planning Tool
Please enter the consumer's information.
What is the consumer's name?
(Required)
What is their date of birth?
(Required)
Phone
(Required)
Email
(Required)
Therapy Services Planning Tool
Are they currently in a facility?
Currently in a facility?
(Required)
Yes
No
What is the name of the facility?
(Required)
What is the address of the facility?
(Required)
What is their address?
(Required)
Therapy Services Planning Tool
Are they covered by insurance?
Covered by insurance?
(Required)
Yes
They need support obtaining coverage.
Unsure
Please provide insurance information (if known)
Therapy Services Planning Tool
What is the cause of this person’s injury?
What is the cause of this person’s injury?
(Required)
Therapy Services Planning Tool
When did the injury occur?
When did the injury occur?
(Required)
Less than 1 year ago
1-5 years ago
6-10 years ago
10+ years ago
Unsure
Therapy Services Planning Tool
What support is this person wanting from Minds Matter?
Select all that apply
What support is this person wanting from Minds Matter?
(Required)
Behavioral Therapy
Cognitive Therapy
Occupational Therapy
Physical Therapy
Speech Therapy
Navigating Home
Unsure
Other
Therapy Services Planning Tool
Who is the best person to reach out to for scheduling?
Best person to reach out to for scheduling?
(Required)
Consumer
Me
Other
What is their name?
(Required)
Phone
(Required)
Email
(Required)
Therapy Services Planning Tool
Other important information/comments:
Other important information/comments:
Therapy Services Planning Tool
How did you hear about Minds Matter, LLC?
How did you hear about Minds Matter, LLC?
(Required)
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