Please complete our 5-minute survey.

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* 1. Select all that apply to you:

Individual with brain injury

Family member of an individual with a brain injury

Provider of professional services to people with brain injury

Brain injury support group leader or participant

Other (please specify)

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* 2. Your zip code:

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* 3. Please indicate your race/ethnicity.

White

Hispanic/Latino

Black or African-American

Native American or American Indian

Asian/Pacific Islander

Other (please specify)

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* 4. How did you hear about the Brain Injury Alliance of Connecticut (BIAC)?

Website

Mailings

Friend or family member

Professional networks

Attending a BIAC event (e.g. Walk for Thought)

Hospital/doctor recommendation

Other (please specify)

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* 5. Are you aware that the Brain Injury Alliance of Connecticut (BIAC) has a HelpLine staffed by certified Brain Injury Specialists who provide individual support and guidance?

Yes

We are seeking to improve the services and programs offered by the Brain Injury Alliance of Connecticut. Select your level of interest for each item in questions 6-12.

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* 6. SUPPORT GROUP for brain injury survivors conducted ONLINE:

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 7. LIVE WEBINARS on brain injury topics conducted by experienced professionals:

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 8. Occasional TEXT MESSAGES for reminders of events, trainings, and support groups hosted by the Brain Injury Alliance of Connecticut:

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 9. "Ask the expert" LIVE ONLINE WEB CHATS with Connecticut-based experts about brain injury issues and resources:

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 10. IN-PERSON TRAINING conducted by Brain Injury Alliance of Connecticut staff members in your class, workplace, or organization:

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 11. "ON-DEMAND" online training by state or national experts (Fee-based with CEUs offered):

Very interested

Somewhat interested

Neutral

Not very interested

Not at all interested

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* 12. I would like more resources, programs, or training on the following topics. Check all that apply.

Introduction to brain injury

Concussion

Accessing brain injury services/resources in another language

Pediatric brain injury (services and supports)

Intimate partner violence and brain injury

Returning to the classroom after a brain injury/concussion ("return to learn")

Returning to play/sports after brain injury/concussion

Returning to work after brain injury

Social and recreational opportunities for individuals with brain injury

Assistive technology for individuals with brain injury

Psychopharmacology after brain injury

Life care planning after brain injury (e.g. trust funds, conservatorship)

Prevention of brain injury

Legislation in Connecticut affecting individuals with brain injury, families, or providers

Understanding disability benefits

Americans with Disabilities Act

Legal issues related to brain injury

Compensatory strategies for optimal independence within the community

Accessing community-based services in Connecticut

Support for caregivers

Other (please specify)

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* 13. If you would like access to brain injury services/resources in another language, please specify the language(s) below:

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* 14. I would be interested in a support group in my area.

Yes (please specify area)

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* 15. (Optional) Provide your contact information if you would like us to follow up with you.

Name

Organization

Email Address

Phone Number

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* 1. Select all that apply to you:

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* 2. Your zip code:

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* 3. Please indicate your race/ethnicity.

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* 4. How did you hear about the Brain Injury Alliance of Connecticut (BIAC)?

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* 5. Are you aware that the Brain Injury Alliance of Connecticut (BIAC) has a HelpLine staffed by certified Brain Injury Specialists who provide individual support and guidance?

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* 6. SUPPORT GROUP for brain injury survivors conducted ONLINE:

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* 7. LIVE WEBINARS on brain injury topics conducted by experienced professionals:

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* 8. Occasional TEXT MESSAGES for reminders of events, trainings, and support groups hosted by the Brain Injury Alliance of Connecticut:

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* 9. "Ask the expert" LIVE ONLINE WEB CHATS with Connecticut-based experts about brain injury issues and resources:

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* 10. IN-PERSON TRAINING conducted by Brain Injury Alliance of Connecticut staff members in your class, workplace, or organization:

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* 11. "ON-DEMAND" online training by state or national experts (Fee-based with CEUs offered):

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* 12. I would like more resources, programs, or training on the following topics. Check all that apply.

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* 13. If you would like access to brain injury services/resources in another language, please specify the language(s) below:

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* 14. I would be interested in a support group in my area.

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* 15. (Optional) Provide your contact information if you would like us to follow up with you.

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* 16. Tell us how BIAC can more effectively provide assistance to you or your community.