CLF HelpLine

Basic Information

First Name

Last Name

Country

Address

City

State/Province

Use abbreviated state name (Ex. New York = NY)

Postal Code

Phone Number

Confirm Email

What is the best way to contact you?

Sex

Race

Date of Birth (MM/DD/YYYY)

Military Service

Military Branch

Military Status - Pre or Post 9/11?

If your service ENDED before 9/11/2001, select "Pre 9/11"

Help Request Information

This section asks about the patient's history of brain trauma exposure. Complete this section to the best of your ability regarding your knowledge of the patient's brain injury history.

Do you feel you or a loved one are experiencing a crisis? Please rate your level of crisis from 1-5, with 1 being "not in crisis" and 5 being "in active emergency".

DISCLAIMER: This is not a crisis helpline, however we can direct you to crisis-related resources

What are you looking for help with?

A recent concussionEnrolling in clinical research studiesLingering concussion symptoms, or Post-Concussion Syndrome (PCS)Symptoms that may be related to Chronic Traumatic Encephalopathy (CTE)Other

If you selected other, what are you looking for help with?

Are you looking for help for yourself or a loved one?

If a loved one, what is your relationship to them?

Patient Age

What exposure have you or your loved one had to brain trauma?

What symptoms are you or your loved one currently experiencing?

What doctor have you or your loved one already seen? Check all that apply:

I haven't seen a doctorI have seen my primary care physicianI have seen one specialistI have seen multiple specialists

If you have seen multiple specialists, please list them:

What treatments have you or your loved one tried?

If no treatment was tried, why?

When did your last brain injury occur?

Is there any other relevant information you would like to share with us?

Referral Information

How did you hear about us?

If you selected other, how did you hear about us?

Contact Information